(1)Existing law specifies the content of a certificate of death and sets forth the persons responsible for completing the certificate of death. Existing law requires certain medical and health content on the certificate.

This bill would prohibit excited delirium, as defined, from being recognized as a valid medical diagnosis or cause of death in this state. The bill would prohibit a coroner, medical examiner, physician, or physician assistant from stating on the certificate of death or in any report that the cause of death was excited delirium.

(2)Existing law designates specified employees and appointees of certain public entities to be peace officers. Existing law grants certain powers to peace officers and prescribes certain requirements and responsibilities for peace officers and their employing or appointing entities.

The bill would prohibit a peace officer from using the term excited delirium to describe an individual in an incident report, but would not prohibit the peace officer from describing an individuals behavior, as specified.

(3)Existing law governs the rules of evidence in every action before the Supreme Court or a court of appeal or superior court, including rules relating to judicial notice, evidentiary burdens, witnesses, opinion testimony and scientific evidence, privileges, evidence affected or excluded by extrinsic policies, hearsay evidence, and writings.

This bill would deem evidence that a person experienced or suffered an excited delirium inadmissible in a civil action, but would not prohibit a party or witness from testifying as to the factual circumstances surrounding the case, including a persons demeanor, conduct, and physical and mental condition, provided it is not attributed to excited delirium.

(1)Existing law specifies the content of a certificate of death and sets forth the persons responsible for completing the certificate of death. Existing law requires certain medical and health content on the certificate.

This bill would prohibit excited delirium, as defined, from being recognized as a valid medical diagnosis or cause of death in this state. The bill would prohibit a coroner, medical examiner, physician, or physician assistant from stating on the certificate of death or in any report that the cause of death was excited delirium.

(2)Existing law designates specified employees and appointees of certain public entities to be peace officers. Existing law grants certain powers to peace officers and prescribes certain requirements and responsibilities for peace officers and their employing or appointing entities.

The bill would prohibit a peace officer from using the term excited delirium to describe an individual in an incident report, but would not prohibit the peace officer from describing an individuals behavior, as specified.

(3)Existing law governs the rules of evidence in every action before the Supreme Court or a court of appeal or superior court, including rules relating to judicial notice, evidentiary burdens, witnesses, opinion testimony and scientific evidence, privileges, evidence affected or excluded by extrinsic policies, hearsay evidence, and writings.

This bill would deem evidence that a person experienced or suffered an excited delirium inadmissible in a civil action, but would not prohibit a party or witness from testifying as to the factual circumstances surrounding the case, including a persons demeanor, conduct, and physical and mental condition, provided it is not attributed to excited delirium.

(1)Existing law specifies the content of a certificate of death and sets forth the persons responsible for completing the certificate of death. Existing law requires certain medical and health content on the certificate.

This bill would prohibit excited delirium, as defined, from being recognized as a valid medical diagnosis or cause of death in this state. The bill would prohibit a coroner or medical examiner coroner, medical examiner, physician, or physician assistant from stating on the certificate of death or in any report that the cause of death was excited delirium.

(2)Existing law designates specified employees and appointees of certain public entities to be peace officers. Existing law grants certain powers to peace officers and prescribes certain requirements and responsibilities for peace officers and their employing or appointing entities.

The bill would prohibit a peace officer from using the term excited delirium to describe an individual in an incident report, but would not prohibit the peace officer from describing an individuals behavior, as specified.

(3)Existing law governs the rules of evidence in every action before the Supreme Court or a court of appeal or superior court, including rules relating to judicial notice, evidentiary burdens, witnesses, opinion testimony and scientific evidence, privileges, evidence affected or excluded by extrinsic policies, hearsay evidence, and writings.

This bill would deem evidence that a person experienced or suffered an excited delirium inadmissible in a civil action, but would not prohibit a party or witness from testifying as to the factual circumstances surrounding the case, including a persons demeanor, conduct, and physical and mental condition, provided it is not attributed to excited delirium.

(1)Existing law specifies the content of a certificate of death and sets forth the persons responsible for completing the certificate of death. Existing law requires certain medical and health content on the certificate.

This bill would prohibit excited delirium, as defined, from being recognized as a valid medical diagnosis or cause of death in this state. The bill would prohibit a coroner or medical examiner from stating on the certificate of death or in any report that the cause of death was excited delirium.

(2)Existing law designates specified employees and appointees of certain public entities to be peace officers. Existing law grants certain powers to peace officers and prescribes certain requirements and responsibilities for peace officers and their employing or appointing entities.

The bill would prohibit a peace officer from using the term excited delirium to describe an individual in an incident report, but would not prohibit the peace officer from describing an individuals behavior, as specified.

(3)Existing law governs the rules of evidence in every action before the Supreme Court or a court of appeal or superior court, including rules relating to judicial notice, evidentiary burdens, witnesses, opinion testimony and scientific evidence, privileges, evidence affected or excluded by extrinsic policies, hearsay evidence, and writings.

This bill would deem evidence that a person experienced or suffered an excited delirium inadmissible in a civil action, but would not prohibit a party or witness from testifying as to the factual circumstances surrounding the case, including a persons demeanor, conduct, and physical and mental condition, provided it is not attributed to excited delirium.

(1)Existing law specifies the content of a certificate of death and sets forth the persons responsible for completing the certificate of death. Existing law requires certain medical and health content on the certificate.

This bill would prohibit excited delirium, as defined, from being recognized as a valid medical diagnosis or cause of death in this state. The bill would prohibit a coroner or medical examiner from stating on the certificate of death or in any report that the cause of death was excited delirium.

(2)Existing law designates specified employees and appointees of certain public entities to be peace officers. Existing law grants certain powers to peace officers and prescribes certain requirements and responsibilities for peace officers and their employing or appointing entities.

The bill would prohibit a peace officer from using the term excited delirium to describe an individual in an incident report, but would not prohibit the peace officer from describing an individuals behavior, as specified.

(1)Existing law specifies the content of a certificate of death and sets forth the persons responsible for completing the certificate of death. Existing law requires certain medical and health content on the certificate.

This bill would prohibit excited delirium, as defined, from being recognized as a valid medical diagnosis or cause of death in this state. The bill would prohibit a coroner or medical examiner from stating on the certificate of death or in any report that the cause of death was excited delirium.

(2)Existing law designates specified employees and appointees of certain public entities to be peace officers. Existing law grants certain powers to peace officers and prescribes certain requirements and responsibilities for peace officers and their employing or appointing entities.

The bill would prohibit a peace officer from using the term excited delirium to describe an individual in an incident report, but would not prohibit the peace officer from describing an individuals behavior, as specified.

(3)Existing law specifies the persons who may bring a civil action for the death of a person caused by the wrongful act or neglect of another. Existing law specifies the admissibility of certain evidence in wrongful death matters.

This bill would prohibit a person from using the term excited delirium as part of an affirmative defense in a civil wrongful death action, but would not prohibit the person from describing an individuals behavior, as specified.

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 360

Author:(Gipson)

As Amended Ver:September 6, 2023

Majority vote

SUMMARY

Provides that "excited delirium" is not a validly recognized medical diagnosis or cause of death in this state.

Senate Amendments

1. Expand the types of employees prohibited from stating on the death certificate that the cause of death was excited delirium to include physicians and physician assistants.
2. Clarify that that the prohibition on a government entity from using excited delirium as a recognized medical diagnosis or cause of death applies to both state and local governments.
3. Clarify how a witness may describe a person's physical or mental condition in court.

COMMENTS

As Passed by the Assembly: This bill provided that "excited delirium" is not a validly recognized medical diagnosis or cause of death in this state.

Major Provisions

1. Defined "excited delirium" as "a term used to describe a person's state of agitation, excitability, paranoia, extreme aggression, physical violence, and apparent immunity to pain that is not listed in the most current version of the Diagnostic and Statistical Manual of Mental Disorders, or for which the court finds there is insufficient scientific evidence or diagnostic criteria to be recognized as a medical condition."
2. Prohibited the recognition of "excited delirium" as a valid medical diagnosis or cause of death in this State.
3. Prohibited a government entity, employee, or contractor from documenting, testifying to, other otherwise using in an official capacity or communication "excited delirium" as a recognized medical diagnosis or cause of death.
4. Prohibited a coroner or medical examiner from listing "excited delirium" as the underlying cause on a death certificate or in any report.
5. Prohibited a peace officer from using the term "excited delirium" to describe an individual in a police report.
6. Provided that evidence that a person suffered from "excited delirium" is inadmissible in any civil action.

Excited Delirium: There is no consistent definition of "excited delirium," but it has been characterized as a state of extreme mental and physiological excitement, featuring agitation, aggression hyperthermia, exceptional strength and endurance without fatigue. (See e.g. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3088378/ ) However, "excited delirium," also sometimes called "agitated delirium," "is not listed in the World Health Organization's International Classification of Diseases nor the Diagnostic and Statistical Manual of Mental Disorders (DMS-5)^[1], tools seen as the standard for medical diagnosis across the world." (https://www.cnn.com/2022/03/12/us/excited-delirium-police-deaths-study/index.html)

In 2009 the American College of Emergency Physicians formally recognized "excited delirium" as a unique syndrome. (https://www.ojp.gov/ncjrs/virtual-library/abstracts/white-paper-report-excited-delirium-syndrome) More recently, however, in 2020 the American Psychiatric Association approved a position statement on concerns about use of the term "Excited Delirium." (https://www.psychiatry.org/File%20Library/About-APA/Organization-Documents-Policies/Position-Use-of-Term-Excited-Delirium.pdf .) Similarly, in 2021 the American Medical Association formally opposed excited delirium as a valid medical diagnosis. (https://www.ama-assn.org/press-center/press-releases/new-ama-policy-opposes-excited-delirium-diagnosis.) Likewise, Physicians for Human Rights takes the position that "excited delirium" is a descriptive term of multiple signs and symptoms, not a medical diagnosis, and accordingly should not be cited as a cause of death. (https://phr.org/our-work/resources/excited-delirium/).

This diagnosis is controversial as the term is generally attributed to sudden unexplained deaths of individuals while in police custody, which may be used as a justification for excessive police force. (https://www.ama-assn.org/press-center/press-releases/new-ama-policy-opposes-excited-delirium-diagnosis) For example, it was relied on by the defense for former Minneapolis police officer Derek Chauvin as a contributing factor in George Floyd's death. (https://apnews.com/article/death-of-george-floyd-health-george-floyd-minneapolis-thomas-lane-1c6776d265e6f3c09e32df7039e80720) A 2020 review in Florida Today showed that nearly two-thirds of the deaths in the state listing the cause of death as "excited delirium" over the past decade occurred while the person who died was either in police custody or had some other interaction with law enforcement. (Excited Delirium: Rare and Deadly Syndrome or a Condition to Excuse Deaths by Police?, A. Sassoon, (Jan. 30, 2020), https://www.floridatoday.com/in-depth/news/2019/10/24/excited-delirium-custody-deaths-gregory-edwards-melbourne-taser/2374304001/) Similarly, an Austin American-Statesman investigation into non-shooting deaths people in police custody in Texas since 2005 revealed that more than one in six of the 289 such deaths have been attributed to "excited delirium." (In Fatal Struggles with Police, a Controversial Killer is Often Blamed, Dexheimer & Schwartz, May 27, 2017, https://www.statesman.com/story/news/investigates/2017/05/27/in-fatal-struggles-with-police-controversial-killer-is-often-blamed/8339157007/)

This bill would prohibit the use of the term "excited delirium" as a valid medical diagnosis or cause of death in this State. It would further prohibit coroners and medical examiners from listing it as a cause of death on a death certificate or autopsy report. Additionally, it would prohibit law enforcement from using the term to describe the condition of an individual in an incident report. Finally, it would be inadmissible as evidence in civil actions.

According to the Author

"I am shocked and appalled that this term, which has never been recognized and has in fact been opposed by the medical community – including in a formal manner by the American Medical Association (AMA) – is used as an official cause of death by county coroners in the state of California."

Arguments in Support

According to the California Public Defenders Association, "Excited Delirium is not a medical diagnosis and the use of certain pharmacological interventions solely for a law enforcement purpose without a medical diagnosis or reason is opposed by major medical and psychiatric associations. In a June 2021policy adopted by physicians, residents, and medical students at the American Medical Association (AMA) the association opposes the use of "excited delirium "as a medical diagnosis and warns against the use of pharmacological interventions without a medical reason. Further, it opposes the use of the term until a clear set of diagnostic criteria has been established. To date, no such diagnostic criteria has been established. The AMA also denounces 'excited delirium'as a sole justification for law enforcement use of excessive force. (AMA policy June 14, 2021.)

"The American Psychiatric Association's (APA) position (approved by the APA Assembly in November 2020 and by the APA Board of Trustees in December 2020) is that the term 'excited delirium' is too non-specific to meaningfully describe and convey information about a person. 'Excited Delirium' should not be used until a clear set of diagnostic criteria are validated. To date, no such clear set of diagnostic criteria have been validated. In their call for detailed study and investigation by the U.S. Department of Health and Human Services, they also call for evidence based protocols to be developed and implemented including barring the use of Ketamine and other sedating medications to achieve incapacitation solely for law enforcement purposes. The APA has not recognized excited delirium as a mental disorder, and it is not included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a manual relied upon by professionals internationally, nor is it found in the International Classification of Diseases.

"While it has been suggested in some articles that the American College of Emergency Physicians (ACEP) has accepted the 'diagnosis' of ExD, the leadership in that organization testified at the trial of Eric Chauvin (for the murder of George Floyd) that the organization had not adopted this policy paper. On the other hand, the American Academy of Emergency Medicine (AAEM ) recognizes that current emergency medicine does not support scientific evidence for "excited delirium" as a medical diagnosis and recommends that ExD should not be used as a cause of death on a death certificate.

"A meta-analysis of ExD and deaths in police custody completed by Physicians for Human Rights, issued March of 2022 found that ExD is a 'go to diagnosis for medical examiners and coroners to use to explain deaths in police custody.' 'A review of the history of the term cannot be disentangled from its racist and unscientific origins'. The AMA finds that the term ExD has been misplaced and diagnosed disproportionally in law enforcement-related deaths of Black and Brown individuals, who are also more likely to experience sedative intervention instead of behavioral de-escalation.

"Excited Delirium is not a valid independent medical or psychiatric diagnosis. There is no clear or consistent definition, established etiology or known underlying pathology.

"For these reasons, on behalf of CPDA, we respectfully urge your 'YES' vote on AB 360 when it comes before you in Assembly Public Safety."

Arguments in Opposition

None submitted.

FISCAL COMMENTS

According to the Senate Appropriations Committee:

1. One-time costs of approximately $50,000 to the Department of Public Health (CDPH) to develop a system that will identify prohibited terms and notify the appropriate medical examiner, coroner, physician or other person who submitted a death certificate that it cannot be completed until the cause of death has been changed to a valid one (General Fund).
2. Potential costs, likely minor and absorbable, to the Commission on Peace Officers Standards and Training (POST) to update training modules related to report writing with instruction regarding the terms prohibited by this bill.

VOTES:

ASM PUBLIC SAFETY: 7-0-1

YES: Jones-Sawyer, Alanis, Bonta, Bryan, Ortega, Santiago, Zbur

ABS, ABST OR NV: Lackey

ASM JUDICIARY: 10-0-1

YES: Maienschein, Essayli, Connolly, Dixon, Haney, Kalra, Pacheco, Papan, Reyes, Robert Rivas

ABS, ABST OR NV: Sanchez

ASSEMBLY FLOOR: 75-0-5

YES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner Horvath, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Cervantes, Chen, Connolly, Megan Dahle, Davies, Dixon, Essayli, Flora, Mike Fong, Vince Fong, Friedman, Gipson, Grayson, Haney, Hart, Holden, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lee, Low, Lowenthal, Maienschein, Mathis, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Rendon

ABS, ABST OR NV: Gabriel, Gallagher, Garcia, Lackey, Sanchez

SENATE FLOOR: 36-1-3

YES: Allen, Alvarado-Gil, Archuleta, Ashby, Atkins, Becker, Blakespear, Bradford, Cortese, Dodd, Durazo, Eggman, Glazer, Gonzalez, Grove, Hurtado, Laird, Limón, McGuire, Menjivar, Min, Newman, Nguyen, Niello, Ochoa Bogh, Padilla, Portantino, Roth, Rubio, Skinner, Smallwood-Cuevas, Stern, Umberg, Wahab, Wiener, Wilk

NO: Seyarto

ABS, ABST OR NV: Caballero, Dahle, Jones

UPDATED

VERSION: September 6, 2023

CONSULTANT: Sandy Uribe / PUB. S. / (916) 319-3744 FN: 0002044

1. The DSM-5 recognizes "delirium" as a clinical entity, with "hyperactive," "hypoactive," and "mixed" delirium subtypes, but not "excited delirium." ↑

 THIRD READING  

Bill No: AB 360

Author: Gipson (D), et al.

Amended: 9/6/23 In Senate

Vote: 21

SENATE PUBLIC SAFETY COMMITTEE: 5-0, 6/6/23

AYES: Wahab, Ochoa Bogh, Bradford, Skinner, Wiener

SENATE JUDICIARY COMMITTEE: 11-0, 6/27/23

AYES: Umberg, Wilk, Allen, Ashby, Caballero, Durazo, Laird, Min, Niello, Stern, Wiener

SENATE APPROPRIATIONS COMMITTEE: 5-1, 9/1/23

AYES: Portantino, Ashby, Bradford, Wahab, Wiener

NOES: Seyarto

NO VOTE RECORDED: Jones

ASSEMBLY FLOOR: 75-0, 4/20/23 - See last page for vote

SUBJECT: Excited delirium

SOURCE: Author

DIGEST:

This bill prohibits “excited delirium” from being recognized as a valid medical diagnosis or cause of death in California, prohibits peace officers from using that term to describe an individual in an incident report, except as specified, and deems evidence that a person experienced “excited delirium” inadmissible in a civil action, as specified.

Senate Floor Amendments of 9/6/23 clarify how a witness may describe a person’s physical or mental condition in court and expands the types of employees that are prohibited from stating on the death certificate that the cause of death was excited delirium.

ANALYSIS:

Existing law:

1. Requires coroners to determine the manner, circumstances and cause of death in the following circumstances:
   1. Violent, sudden or unusual deaths;
   2. Unattended deaths;
   3. When the deceased was not attended by a physician, or registered nurse who is part of a hospice care interdisciplinary team, in the 20 days before death;
   4. When the death is related to known or suspected self-induced or criminal abortion;
   5. Known or suspected homicide, suicide or accidental poisoning;
   6. Deaths suspected as a result of an accident or injury either old or recent;
   7. Drowning, fire, hanging, gunshot, stabbing, cutting, exposure, starvation, acute alcoholism, drug addiction, strangulation, aspiration, or sudden infant death syndrome;
   8. Deaths in whole or in part occasioned by criminal means;
   9. Deaths associated with a known or alleged rape or crime against nature;
   10. Deaths in prison or while under sentence;
   11. Deaths known or suspected as due to contagious disease and constituting a public hazard;
   12. Deaths from occupational diseases or occupational hazards;
   13. Deaths of patients in state mental hospitals operated by the State Department of State Hospitals;
   14. Deaths of patients in state hospitals serving the developmentally disabled operated by the State Department of Development Services;
   15. Deaths where a reasonable ground exists to suspect the death was caused by the criminal act of another; and,
   16. Deaths reported for inquiry by physicians and other persons having knowledge of the death. (Gov. Code, § 27491.)
2. Requires the coroner or a deputy to sign the certificate of death when they perform a mandatory inquiry. (Gov. Code, § 27491, subd. (a).)
3. Allows the coroner or medical examiner discretion when determining the extent of the inquiry required to determine the manner, circumstances and cause of death. (Gov. Code, § 27491, subd. (b).)
4. Requires the coroner or medical examiner to conduct an autopsy at the request of the surviving spouse or other specified persons when an autopsy has not already been performed. (Gov. Code, § 27520, subd. (a).)
5. Allows the coroner or medical examiner discretion to conduct an autopsy at the request of the surviving spouse or other specified persons when an autopsy has already been performed. (Gov. Code, § 27520, subd. (b).)
6. Provides that specified mental health facilities shall not use prone mechanical restraint on a person at risk for positional asphyxiation as a result of specified risk factors known to the provider, including agitated delirium or excited delirium syndromes. (Health and Safety Code § 1180.4, subd. (e).)
7. Makes all relevant evidence admissible, except as otherwise provided by statute. (Evid. Code §351.)
8. Limits or excludes certain specified evidence on the basis of extrinsic policies. (Evid. Code §1100 – 1162.)

This bill:

1. Defines excited delirium as a term used to describe a person’s state of agitation, excitability, paranoia, extreme aggression, physical violence, and apparent immunity to pain that is not listed in the most current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), or for which the court finds there is insufficient scientific evidence or diagnostic criteria to be recognized as a medical condition. Excited delirium includes, but is not limited to, excited delirium syndrome, excited delirium, hyperactive delirium, agitated delirium, and exhaustive mania.
2. Provides that a state or local government entity, or employee or contractor of a state or local government entity, shall not document, testify to, or otherwise use in any official capacity or communication excited delirium as a recognized medical diagnosis or cause of death.
3. Provides that a coroner, medical examiner, physician or physician’s assistant shall not state on the certificate of death, or in any report, that the cause of death was excited delirium. The coroner or medical examiner may list and describe the contributing causes of death, but shall not describe the underlying cause as excited delirium.
4. Provides that a peace officer shall not use the term excited delirium to describe an individual in an incident report completed by a peace officer. A peace officer may describe the characteristics of an individual’s conduct, but shall not generally describe the individual’s demeanor, conduct, or physical and mental condition at issue as excited delirium.
5. Provides that evidence that a person suffered or experienced excited delirium is inadmissible in any civil action. A party or witness may describe the factual circumstances surrounding the case, including a person’s demeanor, conduct, and physical and mental condition at issue, including, but not limited to, a person’s state of agitation, excitability, paranoia, extreme aggression, physical violence, and apparent immunity to pain, but shall not describe or diagnose such demeanor, conduct, or condition as excited delirium, or attribute such demeanor, conduct, or physical and mental condition to excited delirium.

Comments

According to the author, “This issue was brought to my attention through very tragic circumstances. In 2020, Angelo Quinto, a Navy Veteran dealing with a mental health crisis, stopped breathing while two police officers knelt on his back and neck. Mr. Quinto’s official cause of death was determined to be excited delirium. Excited delirium is not a reliable, independent medical or psychiatric diagnosis. There are no diagnostic guidelines, and it is not recognized in the DSM-5, which is the main diagnosis guide for mental health providers. Neither the American Medical Association nor the American Psychiatric Association recognizes this term as a legitimate diagnosis. In fact, the only place where this term is continuously used is to describe deaths that occur in police custody.”

Although there is no consistent definition of “excited delirium,” it has been characterized as a state of extreme mental and physiological excitement, featuring agitation, aggression hyperthermia, exceptional strength and endurance without fatigue. However, “excited delirium,” also sometimes called “agitated delirium,” is not listed in the World Health Organization’s International Classification of Diseases nor the Diagnostic and Statistical Manual of Mental Disorders (DMS-5), tools seen as the standard for medical diagnosis across the world. The DSM-5 recognizes “delirium” as a clinical entity, with “hyperactive,” “hypoactive,” and “mixed” delirium subtypes, but does not recognize “excited delirium.” A new study from doctors at Harvard, the University of Michigan and Massachusetts General Hospital, as well as civil rights lawyers, says the term is ‘scientifically meaningless’ and has become a ‘catch-all for deaths occurring in the context of law enforcement restraint, often coinciding with substance use or mental illness, and disproportionately used to explain the deaths of young Black men in police encounters.’

The term gained some notoriety in California after the December 2020 death of Antioch resident Angelo Quinto, who died in police custody while suffering a mental health episode. Quinto’s family alleged that on the night he was taken into custody, officers knelt on Quinto’s neck for nearly five minutes until he became unresponsive, a claim disputed by police. Quinto died in the hospital three days later, and the Contra Costa County Sheriff-Coroner’s Office ruled that the death was a result of “excited delirium.” That incident was a major impetus behind the effort to pass AB 1608 (Gipson, 2022), which would have required the separation of combined Sheriff-Coroner offices and was also authored by the author of this bill, but failed on the Senate Floor.

Existing law does not contain any meaningful limitations on what constitutes a valid medical diagnosis or official cause of death in this state, or on how government officials may declare those diagnoses or causes of death in their official capacities. This bill expressly prohibits the use of the term “excited delirium” as a valid medical diagnosis or cause of death in California, and prohibits coroners, medical examiners or other government employees from documenting, testifying to or otherwise using that term as a recognized medical diagnosis or cause of death. Under this bill, a coroner, medical examiner, physician or physician’s assistant may list and describe the contributing causes of death, but may not describe the underlying cause as excited delirium, which, according to the definition in this bill, includes hyperactive delirium, agitated delirium, and exhaustive mania. Further, this bill proscribes the use of the term ‘excited delirium’ by peace officers to describe an individual in an incident report. While an officer may describe the characteristics of an individual’s conduct, they may not generally describe the individual’s demeanor, conduct, or physical and mental condition as excited delirium.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: No

According to the Senate Appropriations Committee:

• One-time costs of approximately $50,000 to the Department of Public Health (CDPH) to develop a system that will identify prohibited terms and notify the appropriate medical examiner, coroner, physician or other person who submitted a death certificate that it cannot be completed until the cause of death has been changed to a valid one (General Fund).
• Potential costs, likely minor and absorbable, to the Commission on Peace Officers Standards and Training (POST) to update training modules related to report writing with instruction regarding the terms prohibited by AB 360.

SUPPORT: (Verified 9/6/23)

ACLU California Action

California Attorneys for Criminal Justice

California Faculty Association

California Public Defenders Association

California State Association of Psychiatrists

Consumer Attorneys of California

Disability Rights California

Ella Baker Center for Human Rights

Los Angeles County Board of Supervisors

Los Angeles County District Attorney’s Office

National Association of Social Workers, California Chapter

National Police Accountability Project

Oakland Privacy

Secure Justice

One individual

OPPOSITION: (Verified 9/6/23)

None received

ASSEMBLY FLOOR: 75-0, 4/20/23

AYES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner Horvath, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Cervantes, Chen, Connolly, Megan Dahle, Davies, Dixon, Essayli, Flora, Mike Fong, Vince Fong, Friedman, Gipson, Grayson, Haney, Hart, Holden, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lee, Low, Lowenthal, Maienschein, Mathis, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Rendon

NO VOTE RECORDED: Gabriel, Gallagher, Garcia, Lackey, Sanchez

Prepared by: Alex Barnett / PUB. S. /

9/7/23 11:03:35

**** END ****

SENATE COMMITTEE ON APPROPRIATIONS

Senator Anthony Portantino, Chair

2023 - 2024 Regular Session

AB 360 (Gipson) - Excited delirium

Bill Summary:

AB 360 would prohibit “excited delirium” from being recognized as a valid medical diagnosis or cause of death, prohibit peace officers from using that term to describe an individual in an incident report, and make evidence that a person experienced “excited delirium” inadmissible in a civil action.

Fiscal Impact:

• One-time costs of approximately $50,000 to the Department of Public Health (CDPH) to develop a system that will identify prohibited terms and notify the appropriate medical examiner, coroner, physician or other person who submitted a death certificate that it cannot be completed until the cause of death has been changed to a valid one (General Fund).
  
• Potential costs, likely minor and absorbable, to the Commission on Peace Officers Standards and Training (POST) to update training modules related to report writing with instruction regarding the terms prohibited by AB 360.

Background:

Although there is no consistent definition of “excited delirium,” it has been characterized as a state of extreme mental and physiological excitement, featuring agitation, aggression hyperthermia, exceptional strength and endurance without fatigue. “Excited delirium,” also sometimes called “agitated delirium,” is not listed in the World Health Organization’s International Classification of Diseases nor the Diagnostic and Statistical Manual of Mental Disorders (DMS-5), tools seen as the standard for medical diagnosis across the world. The DSM-5 recognizes “delirium” as a clinical entity, with “hyperactive,” “hypoactive,” and “mixed” delirium subtypes, but does not recognize “excited delirium.”

A report published by the Physicians for Human Rights (PHR), which has been cited by the author and advocates of the bill concluded that “excited delirium” is not a valid, independent medical or psychiatric diagnosis, that there is not a clear, consistent definition of the term, or established diagnostic standards. The term has been widely criticized for its use as a justification for use of force by police.

The California Violent Death Reporting System (CalVDRS) is housed in the Injury and Violence Prevention Branch in the CDPH. CalVDRS is funded by the Centers for Disease Control and Prevention to conduct statewide surveillance on violent deaths that occur in California. Violent deaths include homicide (including legal intervention deaths that result from law enforcement acting in the line of duty), suicide, unintentional firearm deaths, and deaths for which the intent could not be determined. CalVDRS collects data

from multiple sources (death certificates, medical examiner/coroner reports, and law enforcement reports) in order to gain a more comprehensive understanding of the circumstances surrounding these deaths.

Proposed Law:

• Prohibits evidence that a person suffered or experienced excited delirium from being admitted in any civil action. However, a party or witness may describe the factual circumstances surrounding the case, including a person’s demeanor, conduct, and physical and mental condition at issue, but shall not describe or diagnose it as excited delirium, or attribute it to excited delirium.
• Defines “excited delirium” as a term used to describe a person’s state of agitation, excitability, paranoia, extreme aggression, physical violence, and apparent immunity to pain that is not listed in the most current version of the Diagnostic and Statistical Manual of Mental Disorders, or for which the court finds there is insufficient scientific evidence or diagnostic criteria to be recognized as a medical condition. Excited delirium includes, but is not limited to, excited delirium syndrome, excited delirium, hyperactive delirium, agitated delirium, and exhaustive mania.
• Provides that excited delirium shall not be recognized as a valid medical diagnosis or cause of death and a coroner or medical examiner cannot state on the certificate of death, or in any report, that the cause of death was excited delirium. However, it permits a coroner or medical examiner to list and describe the contributing causes of death, but shall not describe the underlying cause as excited delirium.
• Prohibits a government entity, or employee or contractor of a government entity, from documenting, testifying to, or otherwise using in any official capacity or communication excited delirium as a recognized medical diagnosis or cause of death.
• Prohibits a peace officer from using the term excited delirium to describe an individual in an incident report. A peace officer may describe the characteristics of an individual’s conduct, but shall not generally describe the individual’s demeanor, conduct, or physical and mental condition at issue as excited delirium.

-- END --

SENATE JUDICIARY COMMITTEE

Senator Thomas Umberg, Chair

2023-2024 Regular Session

Bill No: AB 360 (Author:Gipson)

Version: March 22, 2023

Hearing Date: June 27, 2023

Fiscal: Yes

Urgency: No

Consultant: CK

SUBJECT

Excited delirium

DIGEST

This bill prohibits evidence that a person suffered “excited delirium” from being admitted in any civil action, used to describe the cause of death in a death certificate, recognized as a valid medical diagnosis, or used by a peace officer in an incident report.

EXECUTIVE SUMMARY

“Excited delirium” is a term increasingly used by medical examiners and law enforcement as a post-mortem explanation for the death of individuals restrained or taken into custody by law enforcement. However, this diagnosis is not a recognized medical or psychiatric diagnosis according to either the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association or the International Classification of Diseases (ICD-9) of the World Health Organization.

Concerns have arisen around the increased usage of this imprecise term and the patterns that have emerged. The term is disproportionately used when describing the condition of individuals who have been harmed or died in police custody, and specifically when the individuals are Black men.

In response, this bill prohibits evidence that a person suffered “excited delirium” from being admitted in any civil action, used to describe the cause of death in a death certificate, recognized as a valid medical diagnosis, or used by a peace officer in an incident report, as specified.

This bill is author-sponsored. It is supported by a wide variety of groups, including the Los Angeles County Board of Supervisors and the Los Angeles County District Attorney’s Office. There is no known opposition. The bill passed out of the Senate Public Safety Committee on a 5 to 0 vote.

PROPOSED CHANGES TO THE LAW

Existing law:

1. States that only relevant evidence is admissible, and except as otherwise provided by statute, all relevant evidence is admissible. (Evid. Code §§ 350, 351.)
2. Defines “relevant evidence” as evidence, including evidence relevant to the credibility of a witness or hearsay declarant, having any tendency in reason to prove or disprove any disputed fact that is of consequence to the determination of the action. (Evid. Code § 210.)
3. Authorizes a court in its discretion to exclude evidence if its probative value is substantially outweighed by the probability that its admission will necessitate undue consumption of time or create substantial danger of undue prejudice, of confusing the issues, or of misleading the jury. (Evid. Code § 352.)
4. Provides, through the Civil Discovery Act, procedures by which parties to a civil action conduct and obtain “discovery.” (Code Civ. Proc. § 2016.010 et seq.)
5. Makes it the duty of the coroner to inquire into and determine the circumstances, manner, and cause of all violent, sudden, or unusual deaths; deaths known or suspected as resulting in whole or in part from or related to accident or injury; deaths in prison or while under sentence; deaths under such circumstances as to afford a reasonable ground to suspect that the death was caused by the criminal act of another; and any deaths reported by physicians or other persons having knowledge of death for inquiry by the coroner. Inquiry pursuant to this section does not include those investigative functions usually performed by other law enforcement agencies. (Gov. Code § 27491.)
6. Requires the coroner or a deputy to personally sign the certificate of death in any case in which the coroner conducts an inquiry. (Gov. Code § 27491(a).)

1. Makes clear that the above provisions do not prohibit the discretion of the coroner to cause to be conducted an autopsy upon any victim of sudden, unexpected, or unexplained death or any death known or suspected of resulting from an accident, suicide, or apparent criminal means, or other death, as specified. (Gov. Code § 27491.4(c).

This bill:

1. Prohibits evidence that a person suffered or experienced excited delirium from being admitted in any civil action. However, a party or witness may describe the factual circumstances surrounding the case, including a person’s demeanor, conduct, and physical and mental condition at issue, but shall not describe or diagnose it as excited delirium, or attribute it to excited delirium.
2. Defines “excited delirium” as a term used to describe a person’s state of agitation, excitability, paranoia, extreme aggression, physical violence, and apparent immunity to pain that is not listed in the most current version of the Diagnostic and Statistical Manual of Mental Disorders, or for which the court finds there is insufficient scientific evidence or diagnostic criteria to be recognized as a medical condition. Excited delirium includes, but is not limited to, excited delirium syndrome, excited delirium, hyperactive delirium, agitated delirium, and exhaustive mania.
3. Provides that excited delirium shall not be recognized as a valid medical diagnosis or cause of death and a coroner or medical examiner cannot state on the certificate of death, or in any report, that the cause of death was excited delirium. However, it permits a coroner or medical examiner to list and describe the contributing causes of death, but shall not describe the underlying cause as excited delirium.
4. Prohibits a government entity, or employee or contractor of a government entity, from documenting, testifying to, or otherwise using in any official capacity or communication excited delirium as a recognized medical diagnosis or cause of death.
5. Prohibits a peace officer from using the term excited delirium to describe an individual in an incident report. A peace officer may describe the characteristics of an individual’s conduct, but shall not generally describe the individual’s demeanor, conduct, or physical and mental condition at issue as excited delirium.

COMMENTS

1. The problem with “excited delirium”

The purpose of the bill is to eliminate use of the term “excited delirium” in official government reporting and as evidence in civil actions. The bill defines it as a term used to describe a person’s state of agitation, excitability, paranoia, extreme aggression, physical violence, and apparent immunity to pain that is not listed in the most current version of the Diagnostic and Statistical Manual of Mental Disorders, or for which the court finds there is insufficient scientific evidence or diagnostic criteria to be recognized as a medical condition. This includes excited delirium syndrome, excited delirium, hyperactive delirium, agitated delirium, and exhaustive mania.

A brief look at the history, usage and medical basis for the term is instructive.

1. The origin and history of “excited delirium” and its racial context

A group of medical doctors with Physicians for Human Rights published an in-depth look at the origins of the term that pinpointed its first usage by several medical professionals, including Dr. Wetli, and the lack of “scientific evidence underpinning” its use as a “cause of death, diagnosis, and unique disease.”^[1] Dr. Wetli infamously used the term to first explain how 12 Black women in Miami who used cocaine had died. Eventually it was discovered that all of the women were actually strangled by a serial killer. The report notes that the doctors’ usage of the term to gravely mischaracterize those asphyxiation deaths, as well as the “racism and misogyny that that seemed to inform it” and his other medical theories, should have discredited the usage of the term, but it only grew. It expanded in one particular context that has motivated the current bill:

A small cohort of authors, many working as researchers or legal defense experts for TASER International (now Axon Enterprise) – a U.S. company that produces technology products and weapons, including the “Taser” line of electroshock weapons marketed as so-called “less-lethal” “stun” weapons – increased the broader use of the term by populating the medical literature with articles about “excited delirium.” In 2007, TASER/Axon purchased many copies of a book entitled Excited Delirium Syndrome written by one of its defense experts, Dr. Vincent Di Maio, and his wife Theresa Di Maio, that built on Wetli’s description of “excited delirium” by describing an “excited delirium syndrome.” They distributed the book for free and also gave out other materials on “excited delirium” at conferences of medical examiners and police chiefs. Seven years later, during a deposition, Dr. Di Maio acknowledged that he and his wife had “come up with” the term “excited delirium syndrome.” The term has come to be used as a catch-all for deaths occurring in the context of law enforcement restraint, often coinciding with substance use or mental illness, and disproportionately used to explain the deaths of young Black men in police encounters.

Ultimately, the report concludes that the term “excited delirium” “cannot be disentangled from its racist and unscientific origins.” The increased and disproportionate usage of the term in law-enforcement related deaths has brought national attention:

On December 23, 2020, Bella Quinto-Collins called 911, seeking help for her 30-year-old brother, Angelo Quinto, who was agitated and exhibiting signs of a mental health crisis at their home in Antioch, California. When two police officers arrived, they pulled Quinto from his mother’s arms onto the floor. At least twice, Quinto’s mother, Cassandra Quinto-Collins, heard him say to the officers, “Please don’t kill me.” Bella and Cassandra then watched in disbelief and horror as the two officers knelt on Quinto’s back for five minutes until he stopped breathing. Three days later, Quinto died in the hospital.

It was not until August 2021 that the family learned the official determination of cause of death: a forensic pathologist testified during a coroner’s inquest that Quinto died from “excited delirium syndrome.”

Angelo Quinto, a Filipino-American Navy veteran, is one of many people, disproportionately people of color, whose deaths at the hands of police have been attributed to “excited delirium” rather than to the conduct of law enforcement officers. In recent years, others have included Manuel Ellis, Zachary Bear Heels, Elijah McClain, Natasha McKenna, and Daniel Prude. “Excited delirium” even emerged as a defense for the officers who killed George Floyd in 2020.

An Austin-American Statesman investigation into each non-shooting death of a person in police custody in Texas from 2005 to 2017 found that more than one in six of these deaths (of 289 total) were attributed to “excited delirium.” A January 2020 Florida Today report found that of 85 deaths attributed to “excited delirium” by Florida medical examiners since 2010, at least 62 percent involved the use of force by law enforcement. A Berkeley professor of law and bioethics conducted a search of these two news databases and three others from 2010 to 2020 and found that of 166 reported deaths in police custody from possible “excited delirium,” Black people made up 43.3 percent and Black and Latinx people together made up at least 56 percent.^[2]

1. “Excited delirium” is unequivocally rejected by established medical community

The term “excited delirium” does not appear as a legitimate medical or psychiatric diagnosis in either the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association or the International Classification of Diseases (ICD-9) of the World Health Organization. The medical community in the United States has unequivocally rejected the term and has called for the cessation of its usage, especially given the troubling usage in law enforcement-involved deaths.

The American Medical Association has specifically adopted a policy opposing use of the term “excited delirium” and stating the troubling patterns that have emerged:

A policy adopted by physicians, residents, and medical students at the American Medical Association’s (AMA) Special Meeting of its House of Delegates (HOD) opposes “excited delirium” as a medical diagnosis and warns against the use of certain pharmacological interventions solely for a law enforcement purpose without a legitimate medical reason.

The new policy addresses reports that show a pattern of using the term “excited delirium” and pharmacological interventions such as ketamine as justification for excessive police force, disproportionately cited in cases where Black men die in law enforcement custody. Specifically, the policy:

• Confirms the AMA’s stance that current evidence does not support “excited delirium” as an official diagnosis, and opposes its use until a clear set of diagnostic criteria has been established
• Denounces “excited delirium” as a sole justification for law enforcement use of excessive force
• Underscores the importance of emergency physician-led oversight of medical emergencies in the field
• Opposes the use of sedative/hypnotic and dissociative drugs—including ketamine—as an intervention for an agitated individual in a law enforcement setting, without a legitimate medical reason
• Recognizes the risk that sedative/hypnotic and dissociative drugs have in relation to an individual’s age, underlying medical conditions, and potential drug interactions when used outside of a hospital setting by a non-physician

Research supporting the new policy echoes current AMA policy recognizing police brutality as a product of structural racism, indicating that racially marginalized and minoritized communities are disproportionately subjected to police force and racial profiling and underscoring the correlation between violent policing and adverse health outcomes. Broadly defined as being in a highly agitated and combative state, studies show that the term “excited delirium” has been misapplied and diagnosed disproportionately in law enforcement-related deaths of Black and Brown individuals, who are also more likely to experience excessive sedative intervention instead of behavioral de-escalation.^[3]

The American Psychiatric Association recently stated its formal, resoundingly clear position: “The term ‘excited delirium’ (ExDs) is too non-specific to meaningfully describe and convey information about a person. ‘Excited delirium’ should not be used until a clear set of diagnostic criteria are validated.” The association further calls for an investigation into the validity of the term and into its troubling and disproportionate usage:

An investigation should be undertaken of cases labelled with “excited delirium” to identify how the term is being used, whether consistent criteria are being applied, and whether it has any validity as a medical syndrome. The U.S. Department of Health and Human Services should conduct a comprehensive, nationwide investigation of instances in which individuals have been identified as being in a state of excited delirium, including in interactions with law enforcement personnel and other out-of-hospital contexts. The study should include examination of all relevant data, including the precipitating events, health outcomes for the individuals and law enforcement personnel, and whether there is a disproportionate application of the term “excited delirium” to persons with mental illness, Black people, or other racial and ethnic groups.^[4]

1. Eliminating use of “excited delirium” in California

This bill addresses the troubling and imprecise usage of the term “excited delirium” by prohibiting its use in various contexts and for specified purposes. First, the bill provides that evidence that a person suffered or experienced “excited delirium” is not admissible in any civil action. Generally, all relevant evidence is admissible in such actions, however there is precedent for limiting relevant evidence that may be problematic for other reasons. For instance, courts have discretion to exclude relevant evidence if its probative value is substantially outweighed by the probability that its admission will create substantial danger of undue prejudice, of confusing the issues, or of misleading the jury.

Second, the bill prohibits government entities, and their employees and contractors, from documenting, testifying to, or using in any official capacity or communication, “excited delirium” as a recognized medical diagnosis or cause of death. Specifically, peace officers are restricted from using the term in incident reports and coroners and medical examiners are prohibiting from stating on certificates of death or other reports that a cause of death was “excited delirium.”

Finally, the bill provides that the term is not to be recognized as a valid medical diagnosis or cause of death in this state.

Given that the term lacks valid and reliable medical basis and is inextricably imbued with racial biases, it is arguably sound policy to eliminate the term’s usage. Importantly, while the bill is limiting the usage of the term in these contexts and for these purposes, it is clear that description of the factual circumstances that are associated with the term are not restricted, so long as they are not diagnosed or attributed to “excited delirium.” Therefore, evidence of a person’s demeanor or conduct is allowed into evidence in a civil case; their agitation or physical violence is still allowed to be described in a police report; and their physical and emotional condition can be listed and described in a medical examiner’s report.

The author explains the motivation for the bill:

This issue was brought to my attention through very tragic circumstances. In 2020, Angelo Quinto, a Navy Veteran dealing with a mental health crisis, stopped breathing while two police officers knelt on his back and neck. Mr. Quinto’s official cause of death was determined to be excited delirium. Excited delirium is not a reliable, independent medical or psychiatric diagnosis. There are no diagnostic guidelines, and it is not recognized in the DSM-5, which is the main diagnosis guide for mental health providers. Neither the American Medical Association nor the American Psychiatric Association recognizes this term as a legitimate diagnosis. In fact, the only place where this term is continuously used is to describe deaths that occur in police custody.

1. Stakeholder positions

The Los Angeles County District Attorney writes in support: “It is clear that the medical community does not recognize excited delirium as a valid medical diagnosis. As such it should not be used by law enforcement or by coroners and medical examiners as a cause of death on a death certificate or autopsy report.”

Writing in support, the Los Angeles County Board of Supervisors asserts:

Excited delirium has been used to rationalize excessive use of force and explain deaths that occur in the context of police restraint on incident reports. Further, it is disproportionately used by police to explain Black male deaths. One systematic review showed that between 2010 and 2020, Black people, who make up 13 percent of the United States population, comprised 43 percent of deaths attributed to excited delirium. As Derek Chauvin knelt on George Floyd’s neck for nine minutes and 29 seconds, he said “I’m worried about excited delirium or whatever,” just before ending Floyd’s life.

AB 360 aims to address this problem, as it would prohibit the use of the term on a death certificate or other reports completed by a coroner or medical examiner and would prohibit police officers from using the term on an incident report. It would also deem evidence that someone experienced excited delirium inadmissible in a civil action.

SUPPORT

California Attorneys for Criminal Justice

California Faculty Association

California Public Defenders Association

California State Association of Psychiatrists (CSAP)

Consumer Attorneys of California

County of Los Angeles Board of Supervisors

Disability Rights California

Ella Baker Center for Human Rights

Los Angeles County District Attorney's Office

National Association of Social Workers, California Chapter

National Police Accountability Project

Oakland Privacy

Secure Justice

OPPOSITION

None known

RELATED LEGISLATION

Pending Legislation: None known.

Prior Legislation: SB 836 (Wiener, Ch. 168, Stats. 2022) reinstated a lapsed prohibition on the disclosure of a person’s immigration status in open court unless the judge presiding over the matter first determines, after a closed hearing, that the evidence is admissible.

PRIOR VOTES:

Senate Public Safety Committee (Ayes 5, Noes 0)

Assembly Floor (Ayes 75, Noes 0)

Assembly Judiciary Committee (Ayes 10, Noes 0)

Assembly Public Safety Committee (Ayes 7, Noes 0)

**************

1. Dr. Brianna da Silva Bhatia, et al., “Excited Delirium” and Deaths in Police Custody: The Deadly Impact of a Baseless Diagnosis (Mar. 2, 2022) Physicians for Human Rights, https://phr.org/our-work/resources/excited-delirium/. All internet citations are current as of June 23, 2023. ↑

2. Ibid. ↑

3. Press Release, New AMA policy opposes “excited delirium” diagnosis (Jun. 14, 2021) American Medical Association, https://www.ama-assn.org/press-center/press-releases/new-ama-policy-opposes-excited-delirium-diagnosis. ↑

4. Position Statement on Concerns About Use of the Term “Excited Delirium” and Appropriate Medical Management in Out-of-Hospital Contexts (Dec. 2020) American Psychiatry Association, https://www.psychiatry.org/getattachment/7769e617-ee6a-4a89-829f-4fc71d831ce0/Position-Use-of-Term-Excited-Delirium.pdf. ↑

SENATE COMMITTEE ON PUBLIC SAFETY

Senator Aisha Wahab, Chair

2023 - 2024 Regular

Bill No: AB 360 Hearing Date: June 6, 2023

Subject: Excited delirium

HISTORY

Source: Author

Prior Legislation: AB 1608 (Gipson, 2022), failed on Senate Floor

Support: ACLU California Action; California Attorneys for Criminal Justice; California Public Defenders Association; California State Association of Psychiatrists; Consumer Attorneys of California; Disability Rights California; Ella Baker Center for Human Rights; Los Angeles County Board of Supervisors; Los Angeles County District Attorney’s Office; National Association of Social Workers, California Chapter; National Police Accountability Project; Oakland Privacy; Secure Justice; One Individual

Opposition: None known

Assembly Floor Vote: 75 - 0

PURPOSE

The purpose of this bill is to prohibit “excited delirium” from being recognized as a valid medical diagnosis or cause of death in California and to prohibit peace officers from using that term to describe an individual in an incident report, except as specified. The bill also deems evidence that a person experienced “excited delirium” inadmissible in a civil action, as specified.

Existing law requires coroners to determine the manner, circumstances and cause of death in the following circumstances:

• • Violent, sudden or unusual deaths;
    
  • Unattended deaths;
    
  • When the deceased was not attended by a physician, or registered nurse who is part of a hospice care interdisciplinary team, in the 20 days before death;
    
  • When the death is related to known or suspected self-induced or criminal abortion;
    
  • Known or suspected homicide, suicide or accidental poisoning;
    
  • Deaths suspected as a result of an accident or injury either old or recent;
    
  • Drowning, fire, hanging, gunshot, stabbing, cutting, exposure, starvation, acute alcoholism, drug addiction, strangulation, aspiration, or sudden infant death syndrome;
    
  • Deaths in whole or in part occasioned by criminal means;
    
  • Deaths associated with a known or alleged rape or crime against nature;
    
  • Deaths in prison or while under sentence;
    
  • Deaths known or suspected as due to contagious disease and constituting a public hazard;
    
  • Deaths from occupational diseases or occupational hazards;
    
  • Deaths of patients in state mental hospitals operated by the State Department of State Hospitals;
    
  • Deaths of patients in state hospitals serving the developmentally disabled operated by the State Department of Development Services;
    
  • Deaths where a reasonable ground exists to suspect the death was caused by the criminal act of another; and,
  • Deaths reported for inquiry by physicians and other persons having knowledge of the death. (Gov. Code, § 27491.)

Existing law requires the coroner or a deputy to sign the certificate of death when they perform a mandatory inquiry. (Gov. Code, § 27491, subd. (a).)

Existing law allows the coroner or medical examiner discretion when determining the extent of the inquiry required to determine the manner, circumstances and cause of death. (Gov. Code, § 27491, subd. (b).)

Existing law requires the coroner or medical examiner to conduct an autopsy at the request of the surviving spouse or other specified persons when an autopsy has not already been performed. (Gov. Code, § 27520, subd. (a).)

Existing law allows the coroner or medical examiner discretion to conduct an autopsy at the request of the surviving spouse or other specified persons when an autopsy has already been performed. (Gov. Code, § 27520, subd. (b).)

Existing law provides that specified mental health facilities shall not use prone mechanical restraint on a person at risk for positional asphyxiation as a result of specified risk factors known to the provider, including agitated delirium or excited delirium syndromes. (Health and Safety Code § 1180.4, subd. (e).)

Existing law makes all relevant evidence admissible, except as otherwise provided by statute. (Evid. Code §351.)

Existing law limits or excludes certain specified evidence on the basis of extrinsic policies. (Evid. Code §1100 – 1162.)

This bill defines excited delirium as a term used to describe a person’s state of agitation, excitability, paranoia, extreme aggression, physical violence, and apparent immunity to pain that is not listed in the most current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), or for which the court finds there is insufficient scientific evidence or diagnostic criteria to be recognized as a medical condition. Excited delirium includes, but is not limited to, excited delirium syndrome, excited delirium, hyperactive delirium, agitated delirium, and exhaustive mania.

This bill provides that excited delirium shall not be recognized as a valid medical diagnosis or cause of death in this state.

This bill provides that a government entity, or employee or contractor of a government entity, shall not document, testify to, or otherwise use in any official capacity or communication excited delirium as a recognized medical diagnosis or cause of death.

This bill provides that a coroner or medical examiner shall not state on the certificate of death, or in any report, that the cause of death was excited delirium. The coroner or medical examiner may list and describe the contributing causes of death, but shall not describe the underlying cause as excited delirium.

This bill provides that a peace officer shall not use the term excited delirium to describe an individual in an incident report completed by a peace officer. A peace officer may describe the characteristics of an individual’s conduct, but shall not generally describe the individual’s demeanor, conduct, or physical and mental condition at issue as excited delirium.

This bill provides that evidence that a person suffered or experienced excited delirium is inadmissible in any civil action. A party or witness may describe the factual circumstances surrounding the case, including a person’s demeanor, conduct, and physical and mental condition at issue, but shall not describe or diagnose such demeanor, conduct, or condition as excited delirium, or attribute such demeanor, conduct, or physical and mental condition to excited delirium.

COMMENTS

1. Need for This Bill

According to the Author:

This issue was brought to my attention through very tragic circumstances. In 2020, Angelo Quinto, a Navy Veteran dealing with a mental health crisis, stopped breathing while two police officers knelt on his back and neck. Mr. Quinto’s official cause of death was determined to be excited delirium. Excited delirium is not a reliable, independent medical or psychiatric diagnosis. There are no diagnostic

guidelines, and it is not recognized in the DSM-5, which is the main diagnosis guide for mental health providers. Neither the American Medical Association nor the American Psychiatric Association recognizes this term as a legitimate diagnosis. In fact, the only place where this term is continuously used is to describe deaths that occur in police custody.

1. Excited Delirium

Although there is no consistent definition of “excited delirium,” it has been characterized as a state of extreme mental and physiological excitement, featuring agitation, aggression hyperthermia, exceptional strength and endurance without fatigue.^[1] However, “excited delirium,” also sometimes called “agitated delirium,” is not listed in the World Health Organization’s International Classification of Diseases nor the Diagnostic and Statistical Manual of Mental Disorders (DMS-5), tools seen as the standard for medical diagnosis across the world.^[2] The DSM-5 recognizes “delirium” as a clinical entity, with “hyperactive,” “hypoactive,” and “mixed” delirium subtypes, but does not recognize “excited delirium.” A new study from doctors at Harvard, the University of Michigan and Massachusetts General Hospital, as well as civil rights lawyers, says the term is ‘scientifically meaningless’ and has become a ‘catch-all for deaths occurring in the context of law enforcement restraint, often coinciding with substance use or mental illness, and disproportionately used to explain the deaths of young Black men in police encounters.’^[3]

Indeed, the controversy surrounding the terminology and diagnosis of “excited delirium” is mainly attributed to sudden unexplained deaths of individuals while in police custody, which may be used as a justification for excessive police force.^[4] For example, it was relied on by the defense for former Minneapolis police officer Derek Chauvin as a contributing factor in George Floyd's death.^[5] Further, a 2020 review in Florida Today showed that nearly two-thirds of the deaths in the state listing the cause of death as “excited delirium” over the past decade occurred while the person who died was either in police custody or had some other interaction with law enforcement.^[6] Another investigation into non-shooting deaths of people in police custody in Texas since 2005 revealed that more than one in six of the 289 such deaths have been attributed to excited delirium.^[7]

Moreover, critics note that the term has racist origins. The organization Physicians for Human Rights traced the history of the term. The term was coined by Drs. Charles Wetli and David Dishbain in 1985 in a case series on cocaine intoxication. The series described seven cocaine users who exhibited fear, panic, violent behavior, hyperactivity, hyperthermia, and/or unexpected strength. All of the individuals had been restrained (six by police and one by emergency room staff) and all died suddenly with respiratory arrest, with five of them reportedly dying in police custody.^[8] Soon thereafter Wetli used this theory to explain how 12 Black women in Miami and were presumed to be sex workers died and were found to have small amounts of cocaine in their systems. Wetli theorized that the combination of cocaine and sex led to sexual excitement and death (though investigators later determined a serial killer was responsible for the deaths. Since all the women were Black, Wetli speculated that cocaine in combination with a blood type more common in Blacks was lethal. At the same time Wetli “continued to promote a corresponding theory of Black male death from cocaine-related delirium, without any scientific basis: “Seventy percent of people dying of coke-induced delirium are black males, even though most users are white. Why? It may be genetic.”^[9]

In 2004, Wetli coauthored a National Association of Medical Examiners position paper that continued to link cocaine use to “excited delirium.” A year later, Theresa Di Maio, a psychiatric nurse, and her husband, Dr. Vincent Di Maio, a forensic pathologist who was the chief medical examiner of a county in Texas and editor of the American Journal of Medicine and Pathology, published a book on “excited delirium syndrome. A few years later, TASER International (now Axon Enterprise), which produces the Taser line of stun guns, purchased copies of the book and began distributing it and other materials on excited delirium at conferences of chiefs of police and medical examiners.^[10]

In 2009, the American College of Emergency Physicians formally recognized “excited delirium” as a unique syndrome.^[11] However, in 2020, the American Psychiatric Association published a position statement on concerns about use of the term, and in 2021, the American Medical Association formally opposed excited delirium as a valid medical diagnosis.^[12] Likewise, Physicians for Human Rights takes the position that “excited delirium” is a descriptive term of multiple signs and symptoms, not a medical diagnosis, and accordingly should not be cited as a cause of death.^[13]

The term gained some notoriety in California after the December 2020 death of Antioch resident Angelo Quinto, who died in police custody while suffering a mental health episode. Quinto’s family alleged that on the night he was taken into custody, officers knelt on Quinto’s neck for nearly 5 minutes until he became unresponsive, a claim disputed by police. Quinto died in the hospital 3 days later, and the Contra Costa County Sheriff-Coroner’s Office ruled that the death was a result of “excited delirium.” That incident was a major impetus behind the effort to pass AB 1608 (Gipson, 2022), which would have required the separation of combined Sheriff-Coroner offices and was also authored by the author of this measure, but failed on the Senate Floor.

As to the use of the term “excited delirium” in law enforcement incident reports, according to information provided to the Assembly Public Safety Committee by the Commission on Peace Officer Standards and Training (POST), the term is not used in either the basic-training program or the field-training program because it is not a recognized medical term. At least some agencies have used the terms in the recent past. For instance, in August 2022, the Bay Area Rapid Transit Police Department issued a new release advising “excited delirium” was removed from BART Police Department policy manual and would no longer be used in their written reports.^[14] Additionally, a 2019 version of the Palo Alto Police Department Policy Manual included a protocol for individuals experiencing “excited delirium,” but the language was altered in the latest version indicating that “excited delirium” is not universally recognized as a medical condition.^[15] The San Jose Police Department has an active training bulletin posted on its website entitled “Management of Subjects in Excited Delirium,” originally published March 19, 2007, suggesting that the term is regularly used in incident reports.^[16]

1. Effect of This Bill

Existing law does not contain any meaningful limitations on what constitutes a valid medical diagnosis or official cause of death in this state, or on how government officials may declare those diagnoses or causes of death in their official capacities. This bill expressly prohibits the use of the term “excited delirium” as a valid medical diagnosis or cause of death in California, and prohibits coroners, medical examiners or other government employees from documenting, testifying to or otherwise using that term as a recognized medical diagnosis or cause of death. Under the bill, a coroner or medical examiner may list and describe the contributing causes of death, but may not describe the underlying cause as excited delirium, which, according to the definition in the bill, includes hyperactive delirium, agitated delirium, and exhaustive mania. Further, the bill proscribes the use of the term ‘excited delirium’ by peace officers to describe an individual in an incident report. While an officer may describe the characteristics of an individual’s conduct, they may not generally describe the individual’s demeanor, conduct, or physical and mental condition as excited delirium.

California law currently contains only one usage of the term “excited delirium,” to describe a factor putting an individual at risk of positional asphyxia and therefore prohibiting the use of a prone mechanical restraint on that individual in specified mental health facilities. The Author may wish to amend the bill to remove or modify that reference in light of the changes proposed in this bill.

1. Double Referral

Should this bill pass out of this committee, it will be heard in Senate Judiciary Committee, which will analyze the provisions of the bill which fall within its jurisdiction.

1. Argument in Support

According to the California Public Defenders Association:

Excited Delirium is not a medical diagnosis and the use of certain pharmacological interventions solely for a law enforcement purpose without a medical diagnosis or reason is opposed by major medical and psychiatric associations. In a June 2021policy adopted by physicians, residents, and medical students at the American Medical Association (AMA) the association opposes the use of “excited delirium “as a medical diagnosis and warns against the use of pharmacological interventions without a medical reason. Further, it opposes the use of the term until a clear set of diagnostic criteria has been established. To date, no such diagnostic criteria has been established. The AMA also denounces “excited delirium” as a sole justification for law enforcement use of excessive force. (AMA policy June 14, 2021.)

The American Psychiatric Association’s (APA) position (approved by the APA Assembly in November 2020 and by the APA Board of Trustees in December 2020) is that the term “excited delirium” is too non-specific to meaningfully describe and convey information about a person. “Excited Delirium” should not be used until a clear set of diagnostic criteria are validated. To date, no such clear set of diagnostic criteria have been validated. In their call for detailed study and investigation by the U.S. Department of Health and Human Services, they also call for evidence based protocols to be developed and implemented including barring the use of Ketamine and other sedating medications to achieve incapacitation solely for law enforcement purposes. The APA has not recognized excited delirium as a mental disorder, and it is not included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a manual relied upon by professionals internationally, nor is it found in the International Classification of Diseases. […]

A meta-analysis of ExD and deaths in police custody completed by Physicians for Human Rights, issued March of 2022 found that ExD is a “go to diagnosis for medical examiners and coroners to use to explain deaths in police custody.” “A review of the history of the term cannot be disentangled from its racist and unscientific origins”. The AMA finds that the term ExD has been misplaced and diagnosed disproportionally in law enforcement-related deaths of Black and Brown individuals, who are also more likely to experience sedative intervention instead of behavioral de-escalation. Excited Delirium is not a valid independent medical or psychiatric diagnosis. There is no clear or consistent definition, established etiology or known underlying pathology.

-- END –

1. Takeuchi, Asia et. al. “Excited Delirium.” Western Journal of Emergency Medicine, 2011 Feb, vol. 12, 77-83. Excited Delirium - PMC (nih.gov) ↑

2. Excited delirium: What is it and why the diagnosis and the term itself should be abandoned, according to a new study | CNN ↑

3. Bhatia, Brianna, et. al. “Excited Delirium and Deaths in Police Custody.” Physicians for Human Rights. 2 March 2022. "Excited Delirium" and Deaths in Police Custody - PHR ↑

4. See, for instance, https://www.ama-assn.org/press-center/press-releases/new-ama-policy-opposes-excited-delirium-diagnosis ↑

5. https://apnews.com/article/death-of-george-floyd-health-george-floyd-minneapolis-thomas-lane-1c6776d265e6f3c09e32df7039e80720 ↑

6. “Excited Delirium: Rare and Deadly Syndrome or a Condition to Excuse Deaths by Police?” Florida Today. 30 Jan 2020. https://www.floridatoday.com/in-depth/news/2019/10/24/excited-delirium-custody-deaths-gregory-edwards-melbourne-taser/2374304001/ ↑

7. Dexheimer and Schwartz, “In Fatal Struggles with Police, a Controversial Killer is Often Blamed.” May 27, 2017., https://www.statesman.com/story/news/investigates/2017/05/27/in-fatal-struggles-with-police-controversial-killer-is-often-blamed/8339157007/.) ↑

8. See Bhatia at pp. 18-19. ↑

9. Id. at pp. 21-23 ↑

10. Id. at pp. 23-26 ↑

11. “ACEP Recognizes Excited Delirium Syndrome.” Emergency Medicine News. 5 October 2009. ACEP Recognizes Excited Delirium Syndrome : Emergency Medicine News (lww.com) ↑

12. “Position Statement on Concerns About Use of the Term “Excited Delirium” and Appropriate Medical Management in Out-of-Hospital Contexts.” Approved December 2020. American Psychiatric Association Position Statement Template (psychiatry.org); “New AMA policy opposes ‘excited delirium’ diagnosis.” 14 June 2021. American Medical Association – Press release. https://www.ama-assn.org/press-center/press-releases/new-ama-policy-opposes-excited-delirium-diagnosis ↑

13. See Bhatia “Executive Summary.” ↑

14. https://www.bart.gov/news/articles/2022/news20220818 ↑

15. See the 2019 version here: redacted-papd-policy-manual-11-19-2019-for-web.pdf (cityofpaloalto.org), at p. 61; and the 2022 version here: policy-manual-for-web-5-3-2023.pdf (cityofpaloalto.org), pp. 60-61. ↑

16. 637236117888330000 (sjpd.org) ↑

SENATE COMMITTEE ON PUBLIC SAFETY

Senator Aisha Wahab, Chair

2023 - 2024 Regular

Bill No: AB 360 Hearing Date: June 6, 2023

Subject: Excited delirium

HISTORY

Source: Author

Prior Legislation: AB 1608 (Gipson, 2022), failed on Senate Floor

Support: ACLU California Action; California Attorneys for Criminal Justice; California Public Defenders Association; Consumer Attorneys of California; Ella Baker Center for Human Rights; Los Angeles County Board of Supervisors; Los Angeles County District Attorney’s Office; National Association of Social Workers, California Chapter; National Police Accountability Project; Oakland Privacy; Secure Justice; One Individual

Opposition: None known

Assembly Floor Vote: 75 - 0

PURPOSE

The purpose of this bill is to prohibit “excited delirium” from being recognized as a valid medical diagnosis or cause of death in California and to prohibit peace officers from using that term to describe an individual in an incident report, except as specified. The bill also deems evidence that a person experienced “excited delirium” inadmissible in a civil action, as specified.

Existing law requires coroners to determine the manner, circumstances and cause of death in the following circumstances:

• • Violent, sudden or unusual deaths;
    
  • Unattended deaths;
    
  • When the deceased was not attended by a physician, or registered nurse who is part of a hospice care interdisciplinary team, in the 20 days before death;
    
  • When the death is related to known or suspected self-induced or criminal abortion;
    
  • Known or suspected homicide, suicide or accidental poisoning;
    
  • Deaths suspected as a result of an accident or injury either old or recent;
    
  • Drowning, fire, hanging, gunshot, stabbing, cutting, exposure, starvation, acute alcoholism, drug addiction, strangulation, aspiration, or sudden infant death syndrome;
    
  • Deaths in whole or in part occasioned by criminal means;
    
  • Deaths associated with a known or alleged rape or crime against nature;
    
  • Deaths in prison or while under sentence;
    
  • Deaths known or suspected as due to contagious disease and constituting a public hazard;
    
  • Deaths from occupational diseases or occupational hazards;
    
  • Deaths of patients in state mental hospitals operated by the State Department of State Hospitals;
    
  • Deaths of patients in state hospitals serving the developmentally disabled operated by the State Department of Development Services;
    
  • Deaths where a reasonable ground exists to suspect the death was caused by the criminal act of another; and,
  • Deaths reported for inquiry by physicians and other persons having knowledge of the death. (Gov. Code, § 27491.)

Existing law requires the coroner or a deputy to sign the certificate of death when they perform a mandatory inquiry. (Gov. Code, § 27491, subd. (a).)

Existing law allows the coroner or medical examiner discretion when determining the extent of the inquiry required to determine the manner, circumstances and cause of death. (Gov. Code, § 27491, subd. (b).)

Existing law requires the coroner or medical examiner to conduct an autopsy at the request of the surviving spouse or other specified persons when an autopsy has not already been performed. (Gov. Code, § 27520, subd. (a).)

Existing law allows the coroner or medical examiner discretion to conduct an autopsy at the request of the surviving spouse or other specified persons when an autopsy has already been performed. (Gov. Code, § 27520, subd. (b).)

Existing law provides that specified mental health facilities shall not use prone mechanical restraint on a person at risk for positional asphyxiation as a result of specified risk factors known to the provider, including agitated delirium or excited delirium syndromes. (Health and Safety Code § 1180.4, subd. (e).)

Existing law makes all relevant evidence admissible, except as otherwise provided by statute. (Evid. Code §351.)

Existing law limits or excludes certain specified evidence on the basis of extrinsic policies. (Evid. Code §1100 – 1162.)

This bill defines excited delirium as a term used to describe a person’s state of agitation, excitability, paranoia, extreme aggression, physical violence, and apparent immunity to pain that is not listed in the most current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), or for which the court finds there is insufficient scientific evidence or diagnostic criteria to be recognized as a medical condition. Excited delirium includes, but is not limited to, excited delirium syndrome, excited delirium, hyperactive delirium, agitated delirium, and exhaustive mania.

This bill provides that excited delirium shall not be recognized as a valid medical diagnosis or cause of death in this state.

This bill provides that a government entity, or employee or contractor of a government entity, shall not document, testify to, or otherwise use in any official capacity or communication excited delirium as a recognized medical diagnosis or cause of death.

This bill provides that a coroner or medical examiner shall not state on the certificate of death, or in any report, that the cause of death was excited delirium. The coroner or medical examiner may list and describe the contributing causes of death, but shall not describe the underlying cause as excited delirium.

This bill provides that a peace officer shall not use the term excited delirium to describe an individual in an incident report completed by a peace officer. A peace officer may describe the characteristics of an individual’s conduct, but shall not generally describe the individual’s demeanor, conduct, or physical and mental condition at issue as excited delirium.

This bill provides that evidence that a person suffered or experienced excited delirium is inadmissible in any civil action. A party or witness may describe the factual circumstances surrounding the case, including a person’s demeanor, conduct, and physical and mental condition at issue, but shall not describe or diagnose such demeanor, conduct, or condition as excited delirium, or attribute such demeanor, conduct, or physical and mental condition to excited delirium.

COMMENTS

1. Need for This Bill

According to the Author:

This issue was brought to my attention through very tragic circumstances. In 2020, Angelo Quinto, a Navy Veteran dealing with a mental health crisis, stopped breathing while two police officers knelt on his back and neck. Mr. Quinto’s official cause of death was determined to be excited delirium. Excited delirium is not a reliable, independent medical or psychiatric diagnosis. There are no diagnostic guidelines, and it is not recognized in the DSM-5, which is the main diagnosis guide for mental health providers. Neither the American Medical Association nor the American Psychiatric Association recognizes this term as a legitimate diagnosis. In fact, the only place where this term is continuously used is to describe deaths that occur in police custody.

1. Excited Delirium

Although there is no consistent definition of “excited delirium,” it has been characterized as a state of extreme mental and physiological excitement, featuring agitation, aggression hyperthermia, exceptional strength and endurance without fatigue.^[1] However, “excited delirium,” also sometimes called “agitated delirium,” is not listed in the World Health Organization’s International Classification of Diseases nor the Diagnostic and Statistical Manual of Mental Disorders (DMS-5), tools seen as the standard for medical diagnosis across the world.^[2] The DSM-5 recognizes “delirium” as a clinical entity, with “hyperactive,” “hypoactive,” and “mixed” delirium subtypes, but does not recognize “excited delirium.” A new study from doctors at Harvard, the University of Michigan and Massachusetts General Hospital, as well as civil rights lawyers, says the term is ‘scientifically meaningless’ and has become a ‘catch-all for deaths occurring in the context of law enforcement restraint, often coinciding with substance use or mental illness, and disproportionately used to explain the deaths of young Black men in police encounters.’^[3]

Indeed, the controversy surrounding the terminology and diagnosis of “excited delirium” is mainly attributed to sudden unexplained deaths of individuals while in police custody, which may be used as a justification for excessive police force.^[4] For example, it was relied on by the defense for former Minneapolis police officer Derek Chauvin as a contributing factor in George Floyd's death.^[5] Further, a 2020 review in Florida Today showed that nearly two-thirds of the deaths in the state listing the cause of death as “excited delirium” over the past decade occurred while the person who died was either in police custody or had some other interaction with law enforcement.^[6] Another investigation into non-shooting deaths of people in police custody in Texas since 2005 revealed that more than one in six of the 289 such deaths have been attributed to excited delirium.^[7]

Moreover, critics note that the term has racist origins. The organization Physicians for Human Rights traced the history of the term. The term was coined by Drs. Charles Wetli and David Dishbain in 1985 in a case series on cocaine intoxication. The series described seven cocaine users who exhibited fear, panic, violent behavior, hyperactivity, hyperthermia, and/or unexpected strength. All of the individuals had been restrained (six by police and one by emergency room staff) and all died suddenly with respiratory arrest, with five of them reportedly dying in police custody.^[8] Soon thereafter Wetli used this theory to explain how 12 Black women in Miami and were presumed to be sex workers died and were found to have small amounts of cocaine in their systems. Wetli theorized that the combination of cocaine and sex led to sexual excitement and death (though investigators later determined a serial killer was responsible for the deaths. Since all the women were Black, Wetli speculated that cocaine in combination with a blood type more common in Blacks was lethal. At the same time Wetli “continued to promote a corresponding theory of Black male death from cocaine-related delirium, without any scientific basis: “Seventy percent of people dying of coke-induced delirium are black males, even though most users are white. Why? It may be genetic.”^[9]

In 2004, Wetli coauthored a National Association of Medical Examiners position paper that continued to link cocaine use to “excited delirium.” A year later, Theresa Di Maio, a psychiatric nurse, and her husband, Dr. Vincent Di Maio, a forensic pathologist who was the chief medical examiner of a county in Texas and editor of the American Journal of Medicine and Pathology, published a book on “excited delirium syndrome. A few years later, TASER International (now Axon Enterprise), which produces the Taser line of stun guns, purchased copies of the book and began distributing it and other materials on excited delirium at conferences of chiefs of police and medical examiners.^[10]

In 2009, the American College of Emergency Physicians formally recognized “excited delirium” as a unique syndrome.^[11] However, in 2020, the American Psychiatric Association published a position statement on concerns about use of the term, and in 2021, the American Medical Association formally opposed excited delirium as a valid medical diagnosis.^[12] Likewise, Physicians for Human Rights takes the position that “excited delirium” is a descriptive term of multiple signs and symptoms, not a medical diagnosis, and accordingly should not be cited as a cause of death.^[13]

The term gained some notoriety in California after the December 2020 death of Antioch resident Angelo Quinto, who died in police custody while suffering a mental health episode. Quinto’s family alleged that on the night he was taken into custody, officers knelt on Quinto’s neck for nearly 5 minutes until he became unresponsive, a claim disputed by police. Quinto died in the hospital 3 days later, and the Contra Costa County Sheriff-Coroner’s Office ruled that the death was a result of “excited delirium.” That incident was a major impetus behind the effort to pass AB 1608 (Gipson, 2022), which would have required the separation of combined Sheriff-Coroner offices and was also authored by the author of this measure, but failed on the Senate Floor.

As to the use of the term “excited delirium” in law enforcement incident reports, according to information provided to the Assembly Public Safety Committee by the Commission on Peace Officer Standards and Training (POST), the term is not used in either the basic-training program or the field-training program because it is not a recognized medical term. At least some agencies have used the terms in the recent past. For instance, in August 2022, the Bay Area Rapid Transit Police Department issued a new release advising “excited delirium” was removed from BART Police Department policy manual and would no longer be used in their written reports.^[14] Additionally, a 2019 version of the Palo Alto Police Department Policy Manual included a protocol for individuals experiencing “excited delirium,” but the language was altered in the latest version indicating that “excited delirium” is not universally recognized as a medical condition.^[15] The San Jose Police Department has an active training bulletin posted on its website entitled “Management of Subjects in Excited Delirium,” originally published March 19, 2007, suggesting that the term is regularly used in incident reports.^[16]

1. Effect of This Bill

Existing law does not contain any meaningful limitations on what constitutes a valid medical diagnosis or official cause of death in this state, or on how government officials may declare those diagnoses or causes of death in their official capacities. This bill expressly prohibits the use of the term “excited delirium” as a valid medical diagnosis or cause of death in California, and prohibits coroners, medical examiners or other government employees from documenting, testifying to or otherwise using that term as a recognized medical diagnosis or cause of death. Under the bill, a coroner or medical examiner may list and describe the contributing causes of death, but may not describe the underlying cause as excited delirium, which, according to the definition in the bill, includes hyperactive delirium, agitated delirium, and exhaustive mania. Further, the bill proscribes the use of the term ‘excited delirium’ by peace officers to describe an individual in an incident report. While an officer may describe the characteristics of an individual’s conduct, they may not generally describe the individual’s demeanor, conduct, or physical and mental condition as excited delirium.

California law currently contains only one usage of the term “excited delirium,” to describe a factor putting an individual at risk of positional asphyxia and therefore prohibiting the use of a prone mechanical restraint on that individual in specified mental health facilities. The Author may wish to amend the bill to remove or modify that reference in light of the changes proposed in this bill.

1. Double Referral

Should this bill pass out of this committee, it will be heard in Senate Judiciary Committee, which will analyze the provisions of the bill which fall within its jurisdiction.

1. Argument in Support

According to the California Public Defenders Association:

Excited Delirium is not a medical diagnosis and the use of certain pharmacological interventions solely for a law enforcement purpose without a medical diagnosis or reason is opposed by major medical and psychiatric associations. In a June 2021policy adopted by physicians, residents, and medical students at the American Medical Association (AMA) the association opposes the use of “excited delirium “as a medical diagnosis and warns against the use of pharmacological interventions without a medical reason. Further, it opposes the use of the term until a clear set of diagnostic criteria has been established. To date, no such diagnostic criteria has been established. The AMA also denounces “excited delirium” as a sole justification for law enforcement use of excessive force. (AMA policy June 14, 2021.)

The American Psychiatric Association’s (APA) position (approved by the APA Assembly in November 2020 and by the APA Board of Trustees in December 2020) is that the term “excited delirium” is too non-specific to meaningfully describe and convey information about a person. “Excited Delirium” should not be used until a clear set of diagnostic criteria are validated. To date, no such clear set of diagnostic criteria have been validated. In their call for detailed study and investigation by the U.S. Department of Health and Human Services, they also call for evidence based protocols to be developed and implemented including barring the use of Ketamine and other sedating medications to achieve incapacitation solely for law enforcement purposes. The APA has not recognized excited delirium as a mental disorder, and it is not included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a manual relied upon by professionals internationally, nor is it found in the International Classification of Diseases. […]

A meta-analysis of ExD and deaths in police custody completed by Physicians for Human Rights, issued March of 2022 found that ExD is a “go to diagnosis for medical examiners and coroners to use to explain deaths in police custody.” “A review of the history of the term cannot be disentangled from its racist and unscientific origins”. The AMA finds that the term ExD has been misplaced and diagnosed disproportionally in law enforcement-related deaths of Black and Brown individuals, who are also more likely to experience sedative intervention instead of behavioral de-escalation. Excited Delirium is not a valid independent medical or psychiatric diagnosis. There is no clear or consistent definition, established etiology or known underlying pathology.

-- END –

1. Takeuchi, Asia et. al. “Excited Delirium.” Western Journal of Emergency Medicine, 2011 Feb, vol. 12, 77-83. Excited Delirium - PMC (nih.gov) ↑

2. Excited delirium: What is it and why the diagnosis and the term itself should be abandoned, according to a new study | CNN ↑

3. Bhatia, Brianna, et. al. “Excited Delirium and Deaths in Police Custody.” Physicians for Human Rights. 2 March 2022. "Excited Delirium" and Deaths in Police Custody - PHR ↑

4. See, for instance, https://www.ama-assn.org/press-center/press-releases/new-ama-policy-opposes-excited-delirium-diagnosis ↑

5. https://apnews.com/article/death-of-george-floyd-health-george-floyd-minneapolis-thomas-lane-1c6776d265e6f3c09e32df7039e80720 ↑

6. “Excited Delirium: Rare and Deadly Syndrome or a Condition to Excuse Deaths by Police?” Florida Today. 30 Jan 2020. https://www.floridatoday.com/in-depth/news/2019/10/24/excited-delirium-custody-deaths-gregory-edwards-melbourne-taser/2374304001/ ↑

7. Dexheimer and Schwartz, “In Fatal Struggles with Police, a Controversial Killer is Often Blamed.” May 27, 2017., https://www.statesman.com/story/news/investigates/2017/05/27/in-fatal-struggles-with-police-controversial-killer-is-often-blamed/8339157007/.) ↑

8. See Bhatia at pp. 18-19. ↑

9. Id. at pp. 21-23 ↑

10. Id. at pp. 23-26 ↑

11. “ACEP Recognizes Excited Delirium Syndrome.” Emergency Medicine News. 5 October 2009. ACEP Recognizes Excited Delirium Syndrome : Emergency Medicine News (lww.com) ↑

12. “Position Statement on Concerns About Use of the Term “Excited Delirium” and Appropriate Medical Management in Out-of-Hospital Contexts.” Approved December 2020. American Psychiatric Association Position Statement Template (psychiatry.org); “New AMA policy opposes ‘excited delirium’ diagnosis.” 14 June 2021. American Medical Association – Press release. https://www.ama-assn.org/press-center/press-releases/new-ama-policy-opposes-excited-delirium-diagnosis ↑

13. See Bhatia “Executive Summary.” ↑

14. https://www.bart.gov/news/articles/2022/news20220818 ↑

15. See the 2019 version here: redacted-papd-policy-manual-11-19-2019-for-web.pdf (cityofpaloalto.org), at p. 61; and the 2022 version here: policy-manual-for-web-5-3-2023.pdf (cityofpaloalto.org), pp. 60-61. ↑

16. 637236117888330000 (sjpd.org) ↑

ASSEMBLY THIRD READING

ATR Bill Id:AB 360

Author:(Gipson)

As Amended Ver:March 22, 2023

Majority vote

SUMMARY

Provides that "excited delirium" is not a validly recognized medical diagnosis or cause of death in this state.

Major Provisions

1. Defines "excited delirium" as "a term used to describe a person's state of agitation, excitability, paranoia, extreme aggression, physical violence, and apparent immunity to pain that is not listed in the most current version of the Diagnostic and Statistical Manual of Mental Disorders, or for which the court finds there is insufficient scientific evidence or diagnostic criteria to be recognized as a medical condition."
2. Prohibits the recognition of "excited delirium" as a valid medical diagnosis or cause of death in this State.
3. Prohibits a government entity, employee, or contractor from documenting, testifying to, other otherwise using in an official capacity or communication "excited delirium" as a recognized medical diagnosis or cause of death.
4. Prohibits a coroner or medical examiner from listing "excited delirium" as the underlying cause on a death certificate or in any report.
5. Prohibits a peace officer from using the term "excited delirium" to describe an individual in a police report.
6. Provides that evidence that a person suffered from "excited delirium" is inadmissible in any civil action.

COMMENTS

Excited Delirium: There is no consistent definition of "excited delirium," but it has been characterized as a state of extreme mental and physiological excitement, featuring agitation, aggression hyperthermia, exceptional strength and endurance without fatigue (See e.g. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3088378/ ). However, "excited delirium," also sometimes called "agitated delirium," "is not listed in the World Health Organization's International Classification of Diseases nor the Diagnostic and Statistical Manual of Mental Disorders (DMS-5)^[1], tools seen as the standard for medical diagnosis across the world" (https://www.cnn.com/2022/03/12/us/excited-delirium-police-deaths-study/index.html).

In 2009 the American College of Emergency Physicians formally recognized "excited delirium" as a unique syndrome (https://www.ojp.gov/ncjrs/virtual-library/abstracts/white-paper-report-excited-delirium-syndrome). More recently, however, in 2020 the American Psychiatric Association approved a position statement on concerns about use of the term "Excited Delirium" (https://www.psychiatry.org/File%20Library/About-APA/Organization-Documents-Policies/Position-Use-of-Term-Excited-Delirium.pdf). Similarly, in 2021 the American Medical Association formally opposed excited delirium as a valid medical diagnosis (https://www.ama-assn.org/press-center/press-releases/new-ama-policy-opposes-excited-delirium-diagnosis). Likewise, Physicians for Human Rights takes the position that "excited delirium" is a descriptive term of multiple signs and symptoms, not a medical diagnosis, and accordingly should not be cited as a cause of death. (https://phr.org/our-work/resources/excited-delirium/).

This diagnosis is controversial as the term is generally attributed to sudden unexplained deaths of individuals while in police custody, which may be used as a justification for excessive police force (https://www.ama-assn.org/press-center/press-releases/new-ama-policy-opposes-excited-delirium-diagnosis). For example, it was relied on by the defense for former Minneapolis police officer Derek Chauvin as a contributing factor in George Floyd's death (https://apnews.com/article/death-of-george-floyd-health-george-floyd-minneapolis-thomas-lane-1c6776d265e6f3c09e32df7039e80720). A 2020 review in Florida Today showed that nearly two-thirds of the deaths in the state listing the cause of death as "excited delirium" over the past decade occurred while the person who died was either in police custody or had some other interaction with law enforcement (Excited Delirium: Rare and Deadly Syndrome or a Condition to Excuse Deaths by Police?, A. Sassoon, (Jan. 30, 2020), https://www.floridatoday.com/in-depth/news/2019/10/24/excited-delirium-custody-deaths-gregory-edwards-melbourne-taser/2374304001/). Similarly, an Austin American-Statesman investigation into non-shooting deaths people in police custody in Texas since 2005 revealed that more than one in six of the 289 such deaths have been attributed to "excited delirium" (In Fatal Struggles with Police, a Controversial Killer is Often Blamed, Dexheimer & Schwartz, May 27, 2017, https://www.statesman.com/story/news/investigates/2017/05/27/in-fatal-struggles-with-police-controversial-killer-is-often-blamed/8339157007/).

This bill would prohibit the use of the term "excited delirium" as a valid medical diagnosis or cause of death in this State. It would further prohibit coroners and medical examiners from listing it as a cause of death on a death certificate or autopsy report. Additionally, it would prohibit law enforcement from using the term to describe the condition of an individual in an incident report. Finally, it would be inadmissible as evidence in civil actions.

According to the Author

"I am shocked and appalled that this term, which has never been recognized and has in fact been opposed by the medical community – including in a formal manner by the American Medical Association (AMA) – is used as an official cause of death by county coroners in the state of California."

Arguments in Support

According to the California Public Defenders Association, "Excited Delirium is not a medical diagnosis and the use of certain pharmacological interventions solely for a law enforcement purpose without a medical diagnosis or reason is opposed by major medical and psychiatric associations. In a June 2021 policy adopted by physicians, residents, and medical students at the American Medical Association (AMA) the association opposes the use of "excited delirium "as a medical diagnosis and warns against the use of pharmacological interventions without a medical reason. Further, it opposes the use of the term until a clear set of diagnostic criteria has been established. To date, no such diagnostic criteria has been established. The AMA also denounces 'excited delirium' as a sole justification for law enforcement use of excessive force (AMA policy June 14, 2021).

"The American Psychiatric Association's (APA) position (approved by the APA Assembly in November 2020 and by the APA Board of Trustees in December 2020) is that the term 'excited delirium' is too non-specific to meaningfully describe and convey information about a person. 'Excited Delirium' should not be used until a clear set of diagnostic criteria are validated. To date, no such clear set of diagnostic criteria have been validated. In their call for detailed study and investigation by the [United States] Department of Health and Human Services, they also call for evidence based protocols to be developed and implemented including barring the use of Ketamine and other sedating medications to achieve incapacitation solely for law enforcement purposes. The APA has not recognized excited delirium as a mental disorder, and it is not included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a manual relied upon by professionals internationally, nor is it found in the International Classification of Diseases.

"While it has been suggested in some articles that the American College of Emergency Physicians (ACEP) has accepted the 'diagnosis' of ExD, the leadership in that organization testified at the trial of Eric Chauvin (for the murder of George Floyd) that the organization had not adopted this policy paper. On the other hand, the American Academy of Emergency Medicine (AAEM) recognizes that current emergency medicine does not support scientific evidence for "excited delirium" as a medical diagnosis and recommends that ExD should not be used as a cause of death on a death certificate.

"A meta-analysis of ExD and deaths in police custody completed by Physicians for Human Rights, issued March of 2022 found that ExD is a 'go to diagnosis for medical examiners and coroners to use to explain deaths in police custody'. 'A review of the history of the term cannot be disentangled from its racist and unscientific origins'. The AMA finds that the term ExD has been misplaced and diagnosed disproportionally in law enforcement-related deaths of Black and Brown individuals, who are also more likely to experience sedative intervention instead of behavioral de-escalation.

"Excited Delirium is not a valid independent medical or psychiatric diagnosis. There is no clear or consistent definition, established etiology or known underlying pathology.

"For these reasons, on behalf of CPDA, we respectfully urge your 'YES' vote on AB 360 when it comes before you in Assembly Public Safety."

Arguments in Opposition

None submitted

FISCAL COMMENTS

Unknown. This bill is keyed non-fiscal by the Legislative Counsel.

VOTES

ASM PUBLIC SAFETY: 7-0-1

YES: Jones-Sawyer, Alanis, Bonta, Bryan, Ortega, Santiago, Zbur

ABS, ABST OR NV: Lackey

ASM JUDICIARY: 10-0-1

YES: Maienschein, Essayli, Connolly, Dixon, Haney, Kalra, Pacheco, Papan, Reyes, Robert Rivas

ABS, ABST OR NV: Sanchez

UPDATED

VERSION: March 22, 2023

CONSULTANT: Sandy Uribe / PUB. S. / (916) 319-3744 FN: 0000167

1. The DSM-5 recognizes "delirium" as a clinical entity, with "hyperactive," "hypoactive," and "mixed" delirium subtypes, but not "excited delirium." ↑

Date of Hearing: March 21, 2023

ASSEMBLY COMMITTEE ON JUDICIARY

Brian Maienschein, Chair

ABPCA Bill Id:AB 360

Author:(Gipson) – As Amended Ver:March 16, 2023

As Proposed to be AmendedAs

SUBJECT: Excited delirium

KEY ISSUE: GIVEN THAT INSUFFICIENT SCIENTIFIC EVIDENCE AND DIAGNOSTIC CRITERIA EXISTS TO RECOGNIZE “EXCITED DELIRIUM” AS A MEDICAL CONDITION, SHOULD USE OF THE TERM IN OFFICIAL GOVERNMENT COMMUNICATIONS AND CIVIL ACTIONS BE LIMITED?

SYNOPSIS

This bill limits use of the term “excited delirium” in a variety of official documents and communications by government entities and officials, including peace officers, and coroners. It prohibits the use of excited delirium as a valid medical diagnosis, a cause of death, or to describe an individual in a police report. It also makes the term inadmissible in all civil actions. While there is no consistent definition of “excited delirium,” it has been characterized as a state of extreme mental and physiological excitement, featuring agitation, aggression hyperthermia, exceptional strength and endurance without fatigue. However, “excited delirium,” also sometimes called “agitated delirium,” “is not listed in the World Health Organization’s International Classification of Diseases nor the Diagnostic and Statistical Manual of Mental Disorders (DMS-5), tools seen as the standard for medical diagnosis across the world.” The DMS-5 recognizes “delirium” as a clinical entity, with “hyperactive,” “hypoactive,” and “mixed” delirium subtypes, but does not recognize “excited delirium.”

This term is controversial given that it is generally attributed to sudden unexplained deaths of individuals while in police custody, which may be used as a justification for excessive police force. For example, it was relied on by the defense for former Minneapolis police officer Derek Chauvin as a contributing factor in George Floyd's death. Moreover, critics note that the term has racist origins. The Commission on Peace Officer Standards and Training (POST) does not use the term in either the basic-training program or the field-training program because it is not a recognized medical term. Nevertheless, it appears to have been recognized by at least some California law enforcement agencies in the past.

The author proposes to make a relatively minor amendment to modify the definition of “excited delirium” to address the fact that some expert witnesses have started using slight variations of the term after negative publicity given to “excited delirium.” The variations of excited delirium describe the same nonspecific conduct and behavior as excited delirium and also are not recognized as medical diagnoses. The amendments are incorporated into the Summary of the bill, below, and explained in the analysis. The bill, previously passed by the Assembly Public Safety Committee by a vote of 7-0-1, is supported by numerous police reform, civil rights, and criminal justice advocacy organizations and has no opposition on file.

SUMMARY: Limits use of the term “excited delirium” in official communications by government entities, peace officers, and coroners and makes the term inadmissible in civil actions. Specifically, this bill:

1. Provides that excited delirium shall not be recognized as a valid medical diagnosis or cause of death in this state.
2. Prohibits a government entity, or employee or contractor of a government entity from documenting, testifying to, or otherwise using in any official capacity or communication, excited delirium as a recognized medical diagnosis or cause of death.
3. Provides that a coroner or medical examiner shall not state on the certificate of death, or in any report, that the cause of death was excited delirium. The coroner or medical examiner may list and describe the contributing causes of death, but shall not describe the underlying cause as excited delirium.
4. Provides that a peace officer shall not use the term excited delirium to describe an individual in an incident report completed by a peace officer. A peace officer may describe the characteristics of an individual’s conduct, but shall not generally describe the individual’s demeanor, conduct, or physical and mental condition at issue as excited delirium.
5. Provides that, pursuant to 6), evidence that a person suffered or experienced excited delirium is inadmissible in any civil action. A party or witness may describe the factual circumstances surrounding the case, including a person’s demeanor, conduct, and physical and mental condition at issue, but shall not describe or diagnose such demeanor, conduct, or condition as excited delirium, or attribute such demeanor, conduct, or physical and mental condition to excited delirium.
6. Adds a section to the Evidence Code, providing that evidence that a person suffered or experienced excited delirium shall not be admitted in any civil action, but allows a party or witness to describe the factual circumstances surrounding the case, including a person’s demeanor, conduct, and physical and mental condition at issue, but shall not describe or diagnose such demeanor, conduct, or condition as excited delirium, or attribute such demeanor, conduct, or physical and mental condition to excited delirium.
7. Defines “excited delirium,” for purposes of the above provisions, to mean “a term used to describe a person’s state of agitation, excitability, paranoia, extreme aggression, physical violence, and apparent immunity to pain that is not listed in the most current version of the Diagnostic and Statistical Manual of Mental Disorders, or for which the court finds there is insufficient scientific evidence or diagnostic criteria to be recognized as a medical condition. “Excited delirium” includes, but is not limited to, excited delirium syndrome, excited delirium, hyperactive delirium, agitated delirium, and exhaustive mania.

EXISTING LAW:

1. Makes, except as otherwise provided by statute, all relevant evidence admissible. (Evidence Code Section 351.)
2. Limits or excludes certain specified evidence on the basis of extrinsic policies. (See Evidence Code Div. 9, Chap. 3 [Sections 1100 – 1162].)
3. Requires coroners to determine the manner, circumstances and cause of death in the following circumstances:
   1. Violent, sudden or unusual deaths;
   2. Unattended deaths;
   3. When the deceased was not attended by a physician, or registered nurse who is part of a hospice care interdisciplinary team, in the 20 days before death;
   4. When the death is related to known or suspected self-induced or criminal abortion;
   5. Known or suspected homicide, suicide, or accidental poisoning;
   6. Deaths suspected as a result of an accident or injury either old or recent;
   7. Drowning, fire, hanging, gunshot, stabbing, cutting, exposure, starvation, acute alcoholism, drug addiction, strangulation, aspiration, or sudden infant death syndrome;
   8. Deaths in whole or in part occasioned by criminal means;
   9. Deaths associated with a known or alleged rape or crime against nature;
   10. Deaths in prison or while under sentence;
   11. Deaths known or suspected as due to contagious disease and constituting a public hazard;
   12. Deaths from occupational diseases or occupational hazards;
   13. Deaths of patients in state mental hospitals operated by the State Department of State Hospitals;
   14. Deaths of patients in state hospitals serving the developmentally disabled operated by the State Department of Development Services;
   15. Deaths where a reasonable ground exists to suspect the death was caused by the criminal act of another; and,
   16. Deaths reported for inquiry by physicians and other persons having knowledge of the death. (Government Code Section 27491.)
4. Requires the coroner or a deputy to sign the certificate of death when they perform a mandatory inquiry. (Government Code Section 27491 (a).)
5. Allows the coroner or medical examiner discretion when determining the extent of the inquiry required to determine the manner, circumstances and cause of death. (Government Code Section 27491 (b).)
6. Requires the coroner or medical examiner to conduct an autopsy at the request of the surviving spouse or other specified persons when an autopsy has not already been performed. (Government Code Section 27520 (a).)
7. Allows the coroner or medical examiner discretion to conduct an autopsy at the request of the surviving spouse or other specified persons when an autopsy has already been performed. (Government Code Section 27520 (b).)

FISCAL EFFECT: As currently in print this bill is keyed non-fiscal.

COMMENTS: This bill limits use of the term “excited delirium” in a variety of official documents and communications by government entities and officials, including peace officers, and coroners. It prohibits the use of excited delirium as a valid medical diagnosis, a cause of death, or to describe an individual in a police report. It also makes the term inadmissible in all civil actions. According the author:

Assembly Bill 360 aims to ban the use of the term “excited delirium” as a legitimate diagnosis or cause of death for those who have lost their lives while in police custody. This bill will work to solve the issue stated above because it will prohibit coroners/medical examiners from using the term “excited delirium” which has been a term used to justify the deaths of those who passed while in police custody. In addition, this term has been used as a catch-all for deaths that occur in the context of police officer restraint, coinciding with substance use or mental illness. This term is also disproportionately used to explain the deaths of young Black men in police encounters. . . . Getting rid of the overly used term “excited delirium” will force people to uncover the underlying issues that exist when these symptoms are presented, rather than grouping all the symptoms into a term that is not medically recognized.

Excited Delirium. There is no consistent definition of “excited delirium,” but it has been characterized as a state of extreme mental and physiological excitement, featuring agitation, aggression hyperthermia, exceptional strength and endurance without fatigue. (See e.g. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3088378/.) However, “excited delirium,” also sometimes called “agitated delirium,” “is not listed in the World Health Organization’s International Classification of Diseases nor the Diagnostic and Statistical Manual of Mental Disorders (DMS-5), tools seen as the standard for medical diagnosis across the world.” (https://www.cnn.com/2022/03/12/us/excited-delirium-police-deaths-study/index.html.) The DMS-5 recognizes “delirium” as a clinical entity, with “hyperactive,” “hypoactive,” and “mixed” delirium subtypes, but does not recognize “excited delirium.”

This term is controversial given that it is generally attributed to sudden unexplained deaths of individuals while in police custody, which may be used as a justification for excessive police force. (https://www.ama-assn.org/press-center/press-releases/new-ama-policy-opposes-excited-delirium-diagnosis.) For example, it was relied on by the defense for former Minneapolis police officer Derek Chauvin as a contributing factor in George Floyd's death. (https://apnews.com/article/death-of-george-floyd-health-george-floyd-minneapolis-thomas-lane-1c6776d265e6f3c09e32df7039e80720.) A 2020 review in Florida Today showed that nearly two-thirds of the deaths in the state listing the cause of death as “excited delirium” over the past decade occurred while the person who died was either in police custody or had some other interaction with law enforcement. (Excited Delirium: Rare and Deadly Syndrome or a Condition to Excuse Deaths by Police?, A. Sassoon, (Jan. 30, 2020), https://www.floridatoday.com/in-depth/news/2019/10/24/excited-delirium-custody-deaths-gregory-edwards-melbourne-taser/2374304001/.) Similarly, an Austin American-Statesman investigation into non-shooting deaths of people in police custody in Texas since 2005 revealed that more than one in six of the 289 such deaths have been attributed to “excited delirium.” (In Fatal Struggles with Police, a Controversial Killer is Often Blamed, Dexheimer & Schwartz, May 27, 2017, https://www.statesman.com/story/news/investigates/2017/05/27/in-fatal-struggles-with-police-controversial-killer-is-often-blamed/8339157007/.)

Moreover, critics note that the term has racist origins. The organization Physicians for Human Rights traced the history of the term. The term was coined by Drs. Charles Wetli and David Dishbain in 1985 in a case series on cocaine intoxication. The series described seven cocaine users who exhibited fear, panic, violent behavior, hyperactivity, hyperthermia, and/or unexpected strength. All of the individuals had been restrained (six by police and one by emergency room staff) and all died suddenly with respiratory arrest, with five of them reportedly dying in police custody. (See “Excited Delirium” and Deaths in Police Custody: The Deadly Impact of a Baseless Diagnosis, Bhati et al., March 2022, pp. 18-19, https://phr.org/our-work/resources/excited-delirium/.) Soon thereafter Wetli used this theory to explain how 12 Black women in Miami presumed to be sex workers died and were found to have small amounts of cocaine in their systems. Wetli theorized that the combination of cocaine and sex led to sexual excitement and death. (Id. at p. 20 [Investigators later came to hold a serial killer responsible for the deaths].) Since all the women were Black, Wetli speculated that cocaine in combination with a blood type more common in Blacks was lethal. (Id. at p. 21.) At the same time, Wetli continued to promote a corresponding racist theory that Black male deaths were caused by cocaine-related delirium, without any scientific basis: “Seventy percent of people dying of coke-induced delirium are black males, even though most users are white. Why? It may be genetic.” (Id. at p. 23.)

In 2004, Wetli coauthored a National Association of Medical Examiners position paper that continued to link cocaine use to “excited delirium.” (“Excited Delirium” and Deaths in Police Custody, supra, at p. 23.) In 2005, Theresa Di Maio, a psychiatric nurse, and her husband, Dr. Vincent Di Maio, a forensic pathologist who was the chief medical examiner of a county in Texas and editor of the American Journal of Medicine and Pathology, published a book on “excited delirium” syndrome. (Id. at p. 24.) A few years later, TASER International (now Axon Enterprise), which produces the Taser line of stun guns, purchased copies of the book and began distributing it and other materials on excited delirium at conferences of chiefs of police and medical examiners. (Id. at p. 26.)

In 2009, the American College of Emergency Physicians formally recognized “excited delirium” as a unique syndrome. (https://www.ojp.gov/ncjrs/virtual-library/abstracts/white-paper-report-excited-delirium-syndrome.) However, in 2020 the American Psychiatric Association approved a position statement on concerns about use of the term “Excited Delirium.” (https://www.psychiatry.org/File%20Library/About-APA/Organization-Documents-Policies/Position-Use-of-Term-Excited-Delirium.pdf.) Similarly, in 2021 the American Medical Association formally opposed excited delirium as a valid medical diagnosis. (https://www.ama-assn.org/press-center/press-releases/new-ama-policy-opposes-excited-delirium-diagnosis.) Likewise, Physicians for Human Rights takes the position that “excited delirium” is a descriptive term of multiple signs and symptoms, not a medical diagnosis, and accordingly should not be cited as a cause of death. (https://phr.org/our-work/resources/excited-delirium/.)

As to the use of the term in law enforcement incident reports, according to the analysis of this bill by the Assembly Committee on Public Safety, the Commission on Peace Officer Standards and Training (POST) does not use the term in either the basic-training program or the field-training program because it is not a recognized medical term. Nevertheless, it appears to have been recognized by at least some California law enforcement agencies in the past. For example, in August 2022, the Bay Area Rapid Transit Police Department issued a news release advised that, “excited delirium” had been removed from BART Police Department policy manual and would no longer be used in agency’s written reports. (https://www.bart.gov/news/articles/2022/news20220818.)

The term also has been used by at least one coroner’s office in California. In December 2020, Angelo Quinto died in police custody while suffering a mental health episode. Quinto’s family alleged that a responding officer knelt on Angelo’s neck for nearly five minutes while another officer restrained his legs, causing Angelo to lose consciousness. He later died at the hospital. The Contra Costa County’s Coroner Office ruled the cause of Angelo’s death to be a result of “excited delirium.” (https://www.mercurynews.com/2021/08/20/death-of-angelo-quinto-after-struggle-with-cops-blamed-on-excited-delirium-a-controversial-diagnosis-the-ama-says-is-used-to-shield-police-violence.)

TASER International has successfully used “excited delirium” as an affirmative defense in civil suits. In 2007, National Public Radio reported that the company has successfully defended itself against at least eight lawsuits involving people who died in police custody, arguing that the cause of death was excited delirium, not the taser. (Tasers Implicated in Excited Delirium Deaths, L. Sullivan, Feb. 27, 2007, https://www.npr.org/2007/02/27/7622314/tasers-implicated-in-excited-delirium-deaths; see also https://www.motherjones.com/politics/2009/02/tasers-delirium-defense/.)

The bill. As introduced, this bill was somewhat vague and problematic. It stated that a “government entity, or employee or contractor of a government entity, shall not acknowledge or otherwise validate excited delirium as a recognized medical diagnosis or cause of death.” But the bill did not specify what it meant for a public employee or contractor to “acknowledge or otherwise validate” the term. And the bill also did not specify whether the prohibition applied just to official actions and statements, or also to private discussions. Could a government official say that they disagreed with the bill (or the new law if the bill were to be signed) without violating this prohibition? Given that government employees have a right, protected by the First Amendment, to express their personal opinions, including about laws and legislation, the bill’s original wording may have violated the free speech rights of government employees and contractors. It also arguably gave public employees and contractors inadequate notice of what actions it prohibited, chilled free speech, and was void for vagueness. (See Federal Communications Comm. v. Fox Television (2009) 567 U.S. 239; NAACP v. Button (1963) 371 U.S. 415.)

Likewise, the introduced version of the bill prohibited the “use” of the term excited delirium “as part of an affirmative defense in a civil wrongful death action,” but did not specify which type of “use” it prohibited. This provision—which could be interpreted to bar the use of the term by anyone involved in a civil wrongful death action -- whether as a party, witness, judge, or juror and whether in court or in public—was also therefore problematic.

As amended on March 16th, the bill more specifically spells out who is subject to its prohibitions. For example, the revised language of the bill states that a government employee or contractor shall not “document, testify to, or otherwise use in any official capacity or communication [emphasis added]” the term excited delirium.

As amended on March 16th, the bill also enacts a new provision in the Evidence Code, providing that evidence that a person suffered or experienced excited delirium is inadmissible in any civil action. The bill now clarifies that a party may describe the factual circumstances surrounding the case, including an individual’s demeanor, conduct and physical and mental condition demeanor at issue, but shall not describe or diagnose such demeanor, conduct, or condition as excited delirium, or attribute such demeanor, conduct, or condition to excited delirium.

By limiting the admission in evidence in only civil proceedings and prohibiting government employees and contractors from using the term in specified documents and for specified purposes, the bill would still appear to allow a person other than a government employee, coroner or medical examiner, or peace officer to use the term excited delirium in a proceeding other than a civil proceeding. Therefore, it appears that the bill would allow a witness (such as a privately employed expert witness) to testify in a criminal proceeding (such as the prosecution of a peace officer for homicide after allegedly causing the death of an inmate or arrestee) and attribute the decedent’s behavior or cause of death as “excited delirium” as part of an affirmative defense. This arguably would undermine the effectiveness of the bill. However, the application of the bill in criminal proceedings and the wisdom of limiting the evidentiary provision of the bill to only civil proceedings is beyond the jurisdiction of the Committee.

Additional author’s amendments. One individual, an attorney who states that she has had two decades of experience litigating wrongful death cases in which excited delirium had been used as an affirmative defense by law enforcement officers who kill or injure persons in their custody, wrote to the Committee in support of the bill, but suggested that the author should expand its definition of “excited delirium.” She suggested the definition should encompass other similar terms – such as “hyperactive delirium” and “agitated delirium”—that some expert witnesses have started using after the negative publicity given to “excited delirium. The variations of excited delirium describe the same nonspecific conduct and behavior and also are not recognized as medical diagnoses. In order to address this issue, the author proposes the following modest modification to the definition of “excited delirium” in the bill:

. . . “excited delirium” means a term used to describe a person’s state of agitation, excitability, paranoia, extreme aggression, physical violence, and apparent immunity to pain that is not listed in the most current version of the Diagnostic and Statistical Manual of Mental Disorders, or for which the court finds there is insufficient scientific evidence and or diagnostic criteria to recognize be recognized as a medical condition. “Excited delirium” includes, but is not limited to, excited delirium syndrome, excited delirium, hyperactive delirium, agitated delirium, and exhaustive mania.

Current statutory law references the Diagnostic and Statistical Manual of Mental Disorders 23 times. The exact phrase --“the most current version of the Diagnostic and Statistical Manual of Mental Disorders” -- is used in Section 5972 of the Welfare & Institutions Code regarding CARE Court. The modified language would also give the court the ability to exclude a newly invented future term that lacks scientific basis.

ARGUMENTS IN SUPPORT: California Attorneys for Criminal Justice write the following in support of the bill:

Excited delirium” has inappropriately been used by some law enforcement officers and agencies to justice incidents of excessive force while individuals are in police custody. Examples include, the recent cases of George Floyd, Elijah McClain, and Manuel Ellis. According to the Brookings Institute, “Excited delirium” is an “imprecise, subjectively defined term, and is subjected to misuse. It draws upon aspects of real medical conditions such as delirium, psychosis, drug intoxication, and sudden cardiac death, but manipulates them to form a broadly-applicable blanket diagnosis that serves the interests of law enforcement and absolves them of accountability.

REGISTERED SUPPORT / OPPOSITION:

Support

California Attorneys for Criminal Justice
California Public Defenders Association
Consumer Attorneys of California
Ella Baker Center for Human Rights
National Police Accountability Project
Oakland Privacy

One individual

Opposition

None on file

Analysis Prepared by: Alison Merrilees / JUD. / (916) 319-2334

Date of Hearing:

Chief Counsel: Sandy Uribe

ASSEMBLY COMMITTEE ON PUBLIC SAFETY

Reginald Byron Jones-Sawyer, Sr., Chair

ABPCA Bill Id:AB 360

Author:(Gipson) – As Introduced Ver:February 1, 2023

SUMMARY:

Provides that “excited delirium” is not a validly recognized medical diagnosis or cause of death. Specifically, this bill:

1. Defines “excited delirium” as “a state of agitation, excitability, paranoia, extreme aggression, physical violence, and apparent immunity to pain.”
   
2. Prohibits the recognition of “excited delirium” as a valid medical diagnosis or cause of death in this State.
   
3. Prohibits a government entity, employee, or contractor from acknowledging “excited delirium” as a recognized medical diagnosis or cause of death.
   
4. Prohibits a coroner or medical examiner from listing “excited delirium” as the underlying cause on a death certificate or in any report.
   
5. Prohibits a peace officer from using the term “excited delirium” to describe an individual in a police report.
   
6. Prohibits a person from using the term “excited delirium” as part of an affirmative defense in a wrongful death suit.

EXISTING LAW:

1. Requires coroners to determine the manner, circumstances and cause of death in the following circumstances:
   
   1. Violent, sudden or unusual deaths;
      
   2. Unattended deaths;
      
   3. When the deceased was not attended by a physician, or registered nurse who is part of a hospice care interdisciplinary team, in the 20 days before death;
      
   4. When the death is related to known or suspected self-induced or criminal abortion;
      
   5. Known or suspected homicide, suicide, or accidental poisoning;
      
   6. Deaths suspected as a result of an accident or injury either old or recent;
      
   7. Drowning, fire, hanging, gunshot, stabbing, cutting, exposure, starvation, acute alcoholism, drug addiction, strangulation, aspiration, or sudden infant death syndrome;
      
   8. Deaths in whole or in part occasioned by criminal means;
      
   9. Deaths associated with a known or alleged rape or crime against nature;
      
   10. Deaths in prison or while under sentence;
       
   11. Deaths known or suspected as due to contagious disease and constituting a public hazard;
       
   12. Deaths from occupational diseases or occupational hazards;
       
   13. Deaths of patients in state mental hospitals operated by the State Department of State Hospitals;
       
   14. Deaths of patients in state hospitals serving the developmentally disabled operated by the State Department of Development Services;
       
   15. Deaths where a reasonable ground exists to suspect the death was caused by the criminal act of another; and,
       
   16. Deaths reported for inquiry by physicians and other persons having knowledge of the death. (Gov. Code, § 27491.)
       
2. Requires the coroner or a deputy to sign the certificate of death when they perform a mandatory inquiry. (Gov. Code, § 27491, subd. (a).)
   
3. Allows the coroner or medical examiner discretion when determining the extent of the inquiry required to determine the manner, circumstances and cause of death. (Gov. Code, § 27491, subd. (b).)
   
4. Requires the coroner or medical examiner to conduct an autopsy at the request of the surviving spouse or other specified persons when an autopsy has not already been performed. (Gov. Code, § 27520, subd. (a).)
   
5. Allows the coroner or medical examiner discretion to conduct an autopsy at the request of the surviving spouse or other specified persons when an autopsy has already been performed. (Gov. Code, § 27520, subd. (b).)
   

FISCAL EFFECT:

Unknown

COMMENTS:

1. Author's Statement: According to the author, “I am shocked and appalled that this term, which has never been recognized and has in fact been opposed by the medical community – including in a formal manner by the American Medical Association (AMA) – is used as an official cause of death by county coroners in the state of California.”
   
2. Excited Delirium: There is no consistent definition of “excited delirium,” but it has been characterized as a state of extreme mental and physiological excitement, featuring agitation, aggression hyperthermia, exceptional strength and endurance without fatigue. (See e.g. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3088378/ ) However, “excited delirium,” also sometimes called “agitated delirium,” “is not listed in the World Health Organization’s International Classification of Diseases nor the Diagnostic and Statistical Manual of Mental Disorders (DMS-5)^[1], tools seen as the standard for medical diagnosis across the world.” (https://www.cnn.com/2022/03/12/us/excited-delirium-police-deaths-study/index.html)
   
   This diagnosis is controversial as the term is generally attributed to sudden unexplained deaths of individuals while in police custody, which may be used as a justification for excessive police force. (https://www.ama-assn.org/press-center/press-releases/new-ama-policy-opposes-excited-delirium-diagnosis) For example, it was relied on by the defense for former Minneapolis police officer Derek Chauvin as a contributing factor in George Floyd's death. (https://apnews.com/article/death-of-george-floyd-health-george-floyd-minneapolis-thomas-lane-1c6776d265e6f3c09e32df7039e80720) A 2020 review in Florida Today showed that nearly two-thirds of the deaths in the state listing the cause of death as “excited delirium” over the past decade occurred while the person who died was either in police custody or had some other interaction with law enforcement. (Excited Delirium: Rare and Deadly Syndrome or a Condition to Excuse Deaths by Police?, A. Sassoon, (Jan. 30, 2020), https://www.floridatoday.com/in-depth/news/2019/10/24/excited-delirium-custody-deaths-gregory-edwards-melbourne-taser/2374304001/) Similarly, an Austin American-Statesman investigation into non-shooting deaths people in police custody in Texas since 2005 revealed that more than one in six of the 289 such deaths have been attributed to “excited delirium.” (In Fatal Struggles with Police, a Controversial Killer is Often Blamed, Dexheimer & Schwartz, May 27, 2017, https://www.statesman.com/story/news/investigates/2017/05/27/in-fatal-struggles-with-police-controversial-killer-is-often-blamed/8339157007/)
   
   Moreover, critics note that the term has racist origins. The organization Physicians for Human Rights traced the history of the term. The term was coined by Drs. Charles Wetli and David Dishbain in 1985 in a case series on cocaine intoxication. The series described seven cocaine users who exhibited fear, panic, violent behavior, hyperactivity, hyperthermia, and/or unexpected strength. All of the individuals had been restrained (six by police and one by emergency room staff) and all died suddenly with respiratory arrest, with five of them reportedly dying in police custody. (See “Excited Delirium” and Deaths in Police Custody: The Deadly Impact of a Baseless Diagnosis, Bhati et al., March 2022, pp. 18-19, https://phr.org/our-work/resources/excited-delirium/) Soon thereafter Wetli used this theory to explain how 12 Black women in Miami and were presumed to be sex workers died and were found to have small amounts of cocaine in their systems. Wetli theorized that the combination of cocaine and sex led to sexual excitement and death.^[2] (Id. at p. 20.) Since all the women were Black, Wetli speculated that cocaine in combination with a blood type more common in Blacks was lethal. (Id. at p. 21.) At the same time Wetli “continued to promote a corresponding theory of Black male death from cocaine-related delirium, without any scientific basis: “Seventy percent of people dying of coke-induced delirium are black males, even though most users are white. Why? It may be genetic.” (Id. at p. 23.) Rather than being discredited for being wrong about the murders, from there the use of the term grew.
   
   In 2004, Wetli coauthored a National Association of Medical Examiners position paper that continued to link cocaine use to “excited delirium.” (“Excited Delirium” and Deaths in Police Custody, supra, at p. 23.) And in 2005, Theresa Di Maio, a psychiatric nurse, and her husband, Dr. Vincent Di Maio, a forensic pathologist who was the chief medical examiner of a county in Texas and editor of the American Journal of Medicine and Pathology, published a book on “excited delirium syndrome. (Id. at p. 24.) A few years later, TASER International (now Axon Enterprise), which produces the Taser line of stun guns, purchased copies of the book and began distributing it and other materials on excited delirium at conferences of chiefs of police and medical examiners. (Id. at p. 26.)
   
   In 2009 the American College of Emergency Physicians formally recognized “excited delirium” as a unique syndrome. (https://www.ojp.gov/ncjrs/virtual-library/abstracts/white-paper-report-excited-delirium-syndrome)
   
   More recently, however, in 2020 the American Psychiatric Association approved a position statement on concerns about use of the term “Excited Delirium.” (https://www.psychiatry.org/File%20Library/About-APA/Organization-Documents-Policies/Position-Use-of-Term-Excited-Delirium.pdf .) Similarly, in 2021 the American Medical Association formally opposed excited delirium as a valid medical diagnosis. (https://www.ama-assn.org/press-center/press-releases/new-ama-policy-opposes-excited-delirium-diagnosis.) Likewise, Physicians for Human Rights takes the position that “excited delirium” is a descriptive term of multiple signs and symptoms, not a medical diagnosis, and accordingly should not be cited as a cause of death. (https://phr.org/our-work/resources/excited-delirium/).
   
   This bill would prohibit the use of the term “excited delirium” as a valid medical diagnosis or cause of death in this State. It would further prohibit coroners and medical examiners from listing it as a cause of death on a death certificate or autopsy report. Additionally, it would prohibit law enforcement from using the term to describe the condition of an individual in an incident report. Finally, it would be prohibited as an affirmative defense in wrongful death civil suits.
   
   As to the use of the term in law enforcement incident reports, the Commission on Peace Officer Standards and Training (POST) has informed this committee that the term is not used in either the basic-training program or the field-training program because it is not a recognized medical term. However, it appears to have been recognized by at least some California law enforcement agencies in the past. For example, in August 2022, the Bay Area Rapid Transit Police Department issued a new release advising “excited delirium” was removed from BART Police Department policy manual and would no longer be used in their written reports. (https://www.bart.gov/news/articles/2022/news20220818)
   
   The term also has been used by at least one coroner’s office in California. In December 2020, Angelo Quinto died in police custody while suffering a mental health episode. Quinto’s family alleged that a responding officer knelt on Angelo’s neck for nearly five minutes while another officer restrained his legs, causing Angelo to lose consciousness. He later died in the hospital. The Contra Costa County’s Coroner Office, which is combined with its Sheriff’s office, ruled the cause of Angelo’s death was a result of “excited delirium.” (https://www.mercurynews.com/2021/08/20/death-of-angelo-quinto-after-struggle-with-cops-blamed-on-excited-delirium-a-controversial-diagnosis-the-ama-says-is-used-to-shield-police-violence.)
   

TASER International has successfully used “excited delirium” as an affirmative defense in civil suits. In 2007, National Public Radio reported that the company has successfully defended itself against at least eight lawsuits involving people who died in police custody, arguing that the cause of death was excited delirium, not the taser. (Tasers Implicated in Excited Delirium Deaths, L. Sullivan, Feb. 27, 2007, https://www.npr.org/2007/02/27/7622314/tasers-implicated-in-excited-delirium-deaths; see also https://www.motherjones.com/politics/2009/02/tasers-delirium-defense/.)

All of the aforementioned uses would be prohibited by this bill.

1. Argument in Support: According to the California Public Defenders Association, “Excited Delirium is not a medical diagnosis and the use of certain pharmacological interventions solely for a law enforcement purpose without a medical diagnosis or reason is opposed by major medical and psychiatric associations. In a June 2021policy adopted by physicians, residents, and medical students at the American Medical Association (AMA) the association opposes the use of “excited delirium “as a medical diagnosis and warns against the use of pharmacological interventions without a medical reason. Further, it opposes the use of the term until a clear set of diagnostic criteria has been established. To date, no such diagnostic criteria has been established. The AMA also denounces ‘excited delirium’as a sole justification for law enforcement use of excessive force. (AMA policy June 14, 2021.)
   
   “The American Psychiatric Association’s (APA) position (approved by the APA Assembly in November 2020 and by the APA Board of Trustees in December 2020) is that the term ‘excited delirium’ is too non-specific to meaningfully describe and convey information about a person. ‘Excited Delirium’ should not be used until a clear set of diagnostic criteria are validated. To date, no such clear set of diagnostic criteria have been validated. In their call for detailed study and investigation by the U.S. Department of Health and Human Services, they also call for evidence based protocols to be developed and implemented including barring the use of Ketamine and other sedating medications to achieve incapacitation solely for law enforcement purposes. The APA has not recognized excited delirium as a mental disorder, and it is not included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a manual relied upon by professionals internationally, nor is it found in the International Classification of Diseases.
   
   “While it has been suggested in some articles that the American College of Emergency Physicians (ACEP) has accepted the ‘diagnosis’ of ExD, the leadership in that organization testified at the trial of Eric Chauvin (for the murder of George Floyd) that the organization had not adopted this policy paper. On the other hand, the American Academy of Emergency Medicine (AAEM ) recognizes that current emergency medicine does not support scientific evidence for “excited delirium” as a medical diagnosis and recommends that ExD should not be used as a cause of death on a death certificate.

“A meta-analysis of ExD and deaths in police custody completed by Physicians for Human Rights, issued March of 2022 found that ExD is a ‘go to diagnosis for medical examiners and coroners to use to explain deaths in police custody.’ ‘A review of the history of the term cannot be disentangled from its racist and unscientific origins’. The AMA finds that the term ExD has been misplaced and diagnosed disproportionally in law enforcement-related deaths of Black and Brown individuals, who are also more likely to experience sedative intervention instead of behavioral de-escalation.

“Excited Delirium is not a valid independent medical or psychiatric diagnosis. There is no clear or consistent definition, established etiology or known underlying pathology.

“For these reasons, on behalf of CPDA, we respectfully urge your ‘YES’ vote on AB 360 when it comes before you in Assembly Public Safety.”

1. Argument in Opposition: None submitted.
   
2. Prior Legislation: AB 1608 (Gipson), of the 2021-2022 Legislative Session, would have removed the ability of counties to consolidate the offices of the sheriff and coroner, and specified that if the offices of sheriff and coroner were consolidated before January 1, 2023, the board of supervisors must separate those offices. AB 1608 failed passage in the Senate.

REGISTERED SUPPORT / OPPOSITION:

Support

California Attorneys for Criminal Justice

California Public Defenders Association

Consumer Attorneys of California

Ella Baker Center for Human Rights

Oakland Privacy

Opposition

None submitted.

Analysis Prepared by:

Sandy Uribe / PUB. S. / (916) 319-3744

1. The DSM-5 recognizes “delirium” as a clinical entity, with “hyperactive,” “hypoactive,” and “mixed” delirium subtypes, but not “excited delirium.” ↑

2. Investigators later came to hold a serial killer responsible for the deaths. ↑