“Excited Delirium” and Deaths in Police Custody

[1]. At the medical center, Quinto passed away after three days. Bella and Cassandra then witnessed in shock and terror as the two law enforcement officers knelt on Quinto’s back for a duration of five minutes until he ceased to breathe. On at least two occasions, Quinto’s mother, Cassandra Quinto-Collins, heard him plead with the officers, saying, “Please refrain from ending my life.” Upon the arrival of two police officers, they forcibly removed Quinto from his mother’s embrace and placed him onto the ground. On December 23, 2020, Bella Quinto-Collins dialed 911, seeking assistance for her 30-year-old brother, Angelo Quinto, who was agitated and displaying indications of a mental health crisis at their residence in Antioch, California.

“During a coroner’s inquest, a forensic pathologist stated that Quinto passed away due to “excited delirium syndrome,” which the family discovered as the official cause of death in August 2021. The revelation occurred in August 2021.”

In 2020, the justification of “excited delirium” arose as a defense for the officers who caused the death of George Floyd. Additional individuals who have died as a result of police actions and have been associated with “excited delirium” include Manuel Ellis, Zachary Bear Heels, Elijah McClain, Natasha McKenna, and Daniel Prude. Angelo Quinto, a Navy veteran of Filipino-American descent, is among the many individuals, particularly people of color, whose deaths at the hands of the police have been attributed to “excited delirium” rather than the actions of law enforcement officers.

At least 56 percent of Latinx and Black people, and 43.3 percent of Black people, were reported to be “excited possible” from police custody deaths in 166 reported cases from 2020 to 2010. A professor of bioethics and law at Berkeley conducted a search of two news databases and found these findings. Additionally, at least 62 percent of deaths attributed to “excited delirium” since 2010 involved the use of force by law enforcement. Medical examiners in Florida attributed at least 85 non-shooting deaths to excited delirium from 2010 to 2005, while in Texas, an investigation into each non-shooting death in police custody from 2010 to 2005 found that at least 62 percent were attributed to excited delirium. This was reported by the American Statesman, an Austin-based newspaper.

The term “excited delirium” cannot be disentangled from its racist and unscientific origins.

Video: Dispelling the Myth of “Excited Delirium”

When did the term “excited delirium” evolve to describe a distinct type of “delirium”? How did the corresponding term “delirium” evolve to become a go-to diagnosis for coroners and medical examiners explaining deaths in custody? What evidence is there that it is indeed a valid diagnosis? What evidence is there that it is indeed a valid diagnosis? This report traces the evolution of the term from when it first appeared in the 1980s to its current applications and views, evaluated through interviews with six experts on substance use disorders and severe mental illness. Additionally, we spoke to two members of families who lost loved ones to police violence for a firsthand account of the harms of continued term use. Through a review of medical literature, news archives, expert witness transcripts, and deposition of wrongful death cases, we reconstructed the history of the term “excited delirium” for presentation to Physicians for Human Rights.

It has been speculated without any scientific basis that the reason why all the black women were dying is because of a certain combination of blood type and cocaine that might be more lethal in common. In relation to the species’ death, he postulated that the female dies and the male becomes psychotic for some reason. After Dr. David Fishbain and Dr. Charles Wetli extended his theory to explain how more than 12 black women in Miami died after consuming small amounts of cocaine, they coined the term “excited delirium” in the first case reports on cocaine intoxication in 1981 and 1985. This report concludes that the term “excited delirium” cannot be disentangled from its unscientific and racist origins.

During the time period of 1980 to 1989, investigators ultimately determined that a serial killer was accountable for the killings of potentially 32 females. Davis ultimately determined that all of the women, a total of 19 at that time, had indeed been killed, with signs of suffocation present in numerous instances. Following the discovery of a deceased 14-year-old girl under similar circumstances but without the presence of cocaine in her system, Dr. Joseph Davis, the chief medical examiner, examined the case records.

“Despite the majority of users being Caucasian, seventy percent of individuals succumbing to delirium caused by cocaine are African American men. The reason behind this disparity could possibly be attributed to genetics,” Wetli persisted in advocating for a corresponding hypothesis regarding the deaths of African American males from cocaine-induced delirium, despite the absence of any scientific evidence supporting it. “I find it difficult to believe that someone can be killed effortlessly while under the influence of cocaine… Cocaine is a stimulant. Moreover, these women were street-smart,” Wetli continued to assert that at least some of the women had died as a result of a combination of sexual activity and cocaine use. This claim persisted even after the suspected perpetrator’s arrest the following year.

Wetli’s grave mischaracterization of the Black women murders in Miami and the theory of gendered and racialized sudden death from cocaine should be equally discredited, instead growing excited about the use of “excited delirium” seemed to inform misogyny and racism.

Mourners at a birthday vigil for Angelo Quinto, who was killed by police in California in December 2020. His death was attributed to “excited delirium syndrome.” Photo: Courtesy of the Quinto-Collins family

[20] In encounters with law enforcement, the term is disproportionately employed to explain the deaths of young African American males and is frequently associated with substance abuse or mental illness, occurring in the context of police restraint. It has become a catch-all phrase for these deaths. [19] During a deposition, Dr. Di Maio admitted that he and his wife had later coined the term “excited delirium syndrome” seven years after its initial use. [18] They distributed the book for free at conferences attended by medical examiners and police chiefs, along with other materials on “excited delirium”. [17] In 2007, TASER/Axon acquired numerous copies of the book titled Excited Delirium Syndrome, authored by one of their defense experts, Dr. Vincent Di Maio, and his wife Theresa Di Maio. This book expanded on Wetli’s description of “excited delirium” by introducing the concept of an “excited delirium syndrome”. [16] The broader application of the term was facilitated by a small group of writers, many of whom worked as researchers or legal defense experts for TASER International (now Axon Enterprise) – an American company that manufactures technology products and weapons, including the “Taser” line of electroshock weapons marketed as “less-lethal” “stun” weapons. These writers populated the medical literature with articles discussing “excited delirium”.

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

Conflicts of interest are prevalent with numerous citations that lack quality and support the diagnosis. Additionally, there is a lack of scientific data and a homogenous body of literature. Neither the American Psychiatric Association nor the American Medical Association currently recognize the validity of the diagnosis. It is also not included as a diagnosis in any version of the International Classification of Diseases or the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Furthermore, there are no diagnostic standards for reporting psychiatric or medical conditions. The underlying pathophysiology and etiology are not known or established, and there is no consistent or clear definition. Therefore, the conclusion that “delirium” is a valid and independent psychiatric or medical diagnosis is not supported by the PHR’s review.

The diagnosis of “excited delirium” is based on misquoted, distorted, and misrepresented foundations. While valid as subtypes, delirium and acknowledge ICD-10 and DSM-5, they do not align with the supposed criteria for “excited delirium” and are described as arising from underlying causes. “Excited delirium” was originally introduced as a diagnosis and standalone cause of death based on the subjective opinions of a few individuals. However, over time, the term has taken on its own meaning and significance, with negative consequences.

The diagnosis of “excited delirium” has been used to justify the aggressive and even fatal tactics police have employed. It is disturbing that these behaviors are often not treated or diagnosed as a substance intoxication or mental illness, which raises concerns about the underlying causes of agitated behavior. Furthermore, the term “excited delirium” is scientifically meaningless because there is a lack of rigorous evidence or consensus to support its diagnosis. Many studies that have used this diagnosis have serious methodological deficiencies, and there is a lack of consensus or well-defined understanding of the syndrome. A review of the medical literature confirms this lack of consensus and evidentiary basis for the diagnosis. Additionally, the use of “excited delirium” to explain agitated behavior conflicts with the interests of law enforcement and TASER/Axon, further highlighting the serious methodological deficiencies in its diagnosis.

In the wake of deaths in custody in the United Kingdom, Canada, and Australia, “excited delirium” has gained international attention. This term refers to a range of medical emergencies that law enforcement agencies are trained to respond to, including conditions such as acute oxygen deprivation, acute psychosis, substance or drug overdoses, and even heart attacks. It is worth noting that not all of these conditions necessarily warrant the same medical response. The acceptance of the term “excited delirium” can be partly attributed to the ongoing training manuals and policies of organizations such as the National Association of Medical Examiners and the American College of Emergency Physicians. However, there are also concerns about the pervasiveness of this term in law enforcement practices.

Currently, there is no rigorous scientific research that examines the prevalence of delirium in people who are not physically restrained. It may be unsurprising or expected for individuals who are ill or scared to have a reaction of being restrained when their breathing is inhibited. Pathologizing resistance to law enforcement may be a reaction to pain, and it is unjust to label it as “impervious” or attribute it to “strength” or “superhuman” abilities. Additionally, the diagnosis of “excited delirium” has been used to perpetuate racist tropes against Black people and men of color.

The term has come to be used as a catch-all for deaths occurring in the context of law enforcement restraint … and disproportionately used to explain the deaths of young Black men in police encounters.

The cause of death, as stated in the autopsy report, is attributed to “excited delirium,” which is characterized by the use of violent methods to forcibly restrain individuals, resulting in asphyxia and other forms of self-induced restraint. First responders, often law enforcement officers, are called upon to use these methods in medical emergencies. It is important to recognize that these individuals may have an underlying diagnosis of “excited delirium,” which is often classified as tachypnea (rapid breathing), tachycardia (rapid heart rate), noncompliance with directions, excessive sweating, acute psychosis, hyperactivity, fear, confusion, and agitation.

One critical step among many to prevent deaths is stopping deaths in police custody, particularly cases where the cause of death is officially determined as “excited delirium.” It is essential to end the use of “excited delirium” as a cited cause of death, as it is a descriptive term that holds a myriad of signs and symptoms, and not a medical diagnosis.

Police in Aurora, CO face off with demonstrators protesting the killing of Elijah McClain. McClain was forcibly subdued by Aurora police while walking home and injected with ketamine by paramedics who diagnosed him with “excited delirium.” McClain suffered a heart attack on the way to the hospital and died four days later. Photo: Andy Cross/MediaNews Group/Denver Post via Getty Images


In the midst of George Floyd’s murder, the comment made by Officer Lane about the concept of “excited delirium” is indicative of the extent to which training and practice of law enforcement in the U.S. Has pervaded. Should I just worry about the excited delirium on his side, as Officer Thomas Lane said, while Officer Derek Chauvin knelt on George Floyd’s neck in Minneapolis in May 2020?

In order to assess the validity of the diagnosis, experts and affected family members need to evaluate the medical history, origins, and literature reviews. However, some have already described the troubled history of this term. The term “excited delirium” has evolved from a description of case reports of people with cocaine intoxication, which has been used by courts, emergency physicians, forensic pathologists, and law enforcement. This report traces how the history of “excited delirium” has evolved.

It is essential to cease the use of “excited delirium” as an officially determined cause of death, particularly in cases of deaths in police custody. This is one critical step among many to stop these preventable deaths.


During a mental health crisis, which can involve the use of substances or behavioral disorders, there has been a significant increase in the percentage of police killings, ranging from 25% to 50%. Many organizations, including the National Medical Association, the American Medical Association, the American Public Health Association, and the American Medical Association, recognize this as a public health crisis. Additionally, it is important to note that people of color are more likely to be killed by the police compared to white individuals, further highlighting the urgency of addressing this public health crisis.

Medical response, instead of law enforcement response, can lead to death or injury, as health emergencies faced by protesters are often neglected. Mental health services, along with social and community services, have advocated for reallocating funds from law enforcement to address police killings and implement reforms for police accountability. The killing of George Floyd by the Minneapolis police in May 2020 sparked widespread protests against systemic racism and police brutality, fueling the Black Lives Matter movement and triggering an unprecedented wave of national and global demonstrations.

In Numerous Regions, the United States Faces a Shortage of Adequate Systems to Address Mental and Behavioral Health Emergencies.

Both of these estimates were higher than the annual estimates from 2008 through 2019. In 2020, more than one in five American adults (21 percent) reported experiencing bipolar disorder or schizophrenia, which are serious mental health conditions. This data was reported by the Substance Abuse and Mental Health Services Administration (SAMHSA), a branch of the U.S. Department of Health and Human Services.

In 2015, a report by the Center for Advocacy Treatment found that civilians with untreated mental illness are 16 times more likely to be killed during encounters with law enforcement than other civilians [31]. This has led to deaths at the hands of law enforcement and in these cases, introducing a trained mental health clinician or counselor instead of a police officer can result in de-escalating the situation. In most jurisdictions, it is the norm to call 911 for emergency services when someone is experiencing a mental health crisis. However, despite the increasing prevalence of mental health conditions in the United States, there remains a lack of appropriate emergency response systems for people in crisis. Additionally, many individuals with severe mental illness were left without proper treatment due to the deinstitutionalization movement that began in the 1950s.

A significant percentage of police killings – anywhere from 25 to 50 percent – occur while responding to mental health, behavioral health, or substance use disorder crises.

The report indicated that “The involvement of law enforcement officials as initial responders in mental health emergencies” was one of the three situations that made up 85 percent of the incidents that took place. OHCHR discovered that globally, including in the United States, there were over 190 documented cases of Black individuals dying while in the custody of law enforcement. OHCHR noted in a 2021 report that law enforcement officers frequently infringe upon the rights of Black individuals facing mental health crises, denying them protection from discrimination based on both their race and disability. These reports were assessed by the Office of the United Nations High Commissioner for Human Rights (OHCHR).

“[32] The delivery of basic life support and appropriate care, as well as considerations for the well-being of the individual, can appear dangerous to law enforcement officials, leading them to perceive the victim as someone who reinforces disability-based stereotypes and racial biases. Instead, the police often fail to identify individuals in mental distress as victims and neglect their rights-based need for mental health support. Furthermore, when acting as first responders, police interventions, including the use of restraints during crisis de-escalation protocols, may often exacerbate the situation, aggravating the crisis faced by a person experiencing a mental health crisis. According to the analysis conducted by OHCHR, several incidents occurred where emergency services failed to provide appropriate crisis interventions after receiving calls for assistance from individuals seeking emergency mental health services.”

“When you’re dealing with severe mental illness, and especially when you’re a Black family or a brown family, you pause before you call the police.”

Sabah Muhammad, attorney and legislative and policy counsel, Treatment Advocacy Center

Jurisdictional Variations Exist in the Standards for Death Investigations in the United States

The methods used by officials to investigate and determine the cause of death vary depending on the state and local jurisdiction in the United States. Different types of deaths require investigations or autopsies based on the regulations of each state. The death investigation systems can be categorized into medical examiner systems and coroner systems, which exhibit significant variations. When it comes to cases involving homicide, suspicion of crime, or foul play, including instances of police violence, it is the responsibility of a coroner or medical examiner to lead an investigation and ascertain the circumstances surrounding the individual’s demise. In most states, coroners are not required to possess medical qualifications, while medical examiners are physicians, although not necessarily forensic pathologists. Forensic pathologists specialize in the field of pathology and operate at the intersection of law and medicine to determine the cause of death. Across different states, a variety of systems are in place, including those with appointed medical examiners and/or coroners, elected coroners and appointed medical examiners, a combination of elected and appointed coroners, and a combination of elected and appointed medical examiners. It should be noted that although there are no national standards or universal definitions, deaths occurring in custody are generally defined as “deaths of persons who have been arrested or otherwise detained” by law enforcement officials.

“In 2009, the National Academy of Sciences (NAS) recommended that Congress should authorize appropriate incentive funds to the National Institute of Forensic Science (NIFS) in order to establish medical examiner systems, with the goal of eventually eliminating and replacing existing coroner systems, and ensuring that all medicolegal autopsies are supervised or performed by a board-certified forensic pathologist.”

Under-Reported Instances of Deaths Related to Law Enforcement

Deaths that occur during or after interactions with law enforcement are not always properly reported, monitored, or investigated. There is compelling evidence that more than half of all police killings in 2015 were inaccurately classified as not resulting from police officer interactions, as revealed by a 2017 Harvard study. The study also uncovered a pattern of regularly reported results that downplayed the accountability of police officers to coroners and medical examiners. By comparing data from The Guardian’s “The Counted,” an investigative project on police killings, with data from the National Vital Statistics System (NVSS), a U.S. Federal government system that collects death certificate data and identifies law enforcement-related deaths, the study found a significant disparity. Specifically, the study compared the two datasets using a corresponding diagnostic code called “legal intervention.” The Guardian’s data set revealed a considerably higher number of law enforcement-related deaths compared to the NVSS. Moreover, the study discovered that 55.2 percent of all misclassified police killings were recorded in the NVSS, and deaths in low-income areas were disproportionately underreported.

A 2021 study found that the National Vital Statistics System, the most comprehensive mortality database in the United States, failed to report “55.5 percent of all deaths attributable to police violence,” missing about 17,100 deaths from 1980 to 2019.

[45] Different ethnic groups of individuals who are not of Hispanic origin, eventually followed by individuals who are not of Hispanic origin and are of White race, any ethnic group of individuals who are of Hispanic origin, and individuals who are not of Hispanic origin and are of Black race, had the highest mortality rates as a result of encounters with law enforcement. The research also revealed that the mortality rate due to police violence increased by 38.4 percent from the 1980s to the 2000s, and the NVSS (National Vital Statistics System) failed to document “55.5 percent of all deaths caused by police violence,” omitting approximately 17,100 deaths between 1980 and 2019.[44] A 2021 Lancet study compared “Mapping Police Violence” and “Fatal Encounters,” two other databases based on media sources, to the NVSS in terms of police violence, and it demonstrated that the NVSS failed to report “55.5 percent of all deaths caused by police violence.” Similarly.

Issues with the System and the Capability to Manipulate the Reporting Process Contribute to the Underestimation of Deaths Related to Law Enforcement

Several factors contribute to the under-counting of deaths related to law enforcement. One oft-cited reason is the lack of independence of medical examiners and coroners. In a 2011 survey conducted by the National Association of Medical Examiners, 22 percent of respondents, who were members of the organization, reported experiencing political pressure from appointed or elected officials to change the manner or cause of death listed on death certificates. Conflicts of interest can arise from the inclusion of police departments as part of the system, with many medical examiners also working for law enforcement. Another contributing factor to under-counting is the lack of well-established guidelines and standards. Many death certificates have open-ended sections where it is not explicitly instructed to note whether there was police involvement. This lack of explicit instructions or standards can lead to errors in classification. Moreover, there is no national definition for the manner of death in police custody. Some medical examiners face difficulty in determining whether a case involving restraint, such as “hog-tying,” should be classified as “undetermined,” “accident,” or “homicide.” The lack of sufficient training and knowledge among examiners and coroners further contributes to classification errors. Additionally, the fear of litigation and previous threats of litigation have influenced some medical examiners to modify their forensic findings, resulting in inaccurate documentation. Another survey conducted among 222 medical examiners revealed that approximately 13.5 percent of respondents acknowledged modifying their findings due to previous litigation threats. Approximately 32.5 percent expressed concern that these considerations would impact their future decisions, and 30 percent expressed fear of litigation affecting their diagnostic abilities. This lack of independence among forensic scientists is compounded by the lack of standards, further exacerbated by undue political or law enforcement pressure.

Black Lives Matter protesters march across the Brooklyn Bridge in New York City on May 25, 2021, on the first anniversary of George Floyd’s death at the hands of police. Photo: Andy Cross/Spencer Platt/Getty Images


Physicians are seeking to understand the complex history, origins, and current usage of “excited delirium” through multiple strands of inquiry, in relation to the validity and usage of Human Rights.


PHR acquired extra deposition transcripts and court records from civil rights lawyers John Burton and Ben Nisenbaum. PHR collaborated with civil rights lawyer Julia Sherwin, who, after almost twenty years of dedication, has amassed a vast collection of news archives, deposition transcripts, court documents, and articles pertaining to the beginnings and chronicles of “excited delirium.” As a component of PHR’s systematic effort to record the beginnings, history, and development of the term and notion of “excited delirium,”

Review of Medical Literature

Review article was performed, and a full review of the article was conducted. If the abstract was unclear or not available, the abstracts and titles were screened for information on diagnostic criteria and pathophysiology of the syndrome. Between January 1956 and August 2021, a total of 226 abstracts were found. A PubMed/MEDLINE search was conducted using key words “delirium” without any filters. On August 19, 2021, a scoping review of medical literature was conducted by the team members of PHR, who are physicians, to examine the quality and extent of evidence for delirium as a potential cause of death and its diagnosis.

Articles that focused solely on a case report or series, drugs, or treatment without significant discussion of “excited delirium” as a separate entity were excluded. Out of the 226 articles, 180 did not meet the above criteria and were not included in our analysis, leaving us with 46 peer-reviewed articles. We also conducted a secondary search on the same database using the term “excited delirium syndrome,” which yielded 95 results. However, all of these results were already included in the primary search. It is worth noting that we did not use alternate search terms such as “Bell’s mania,” “agitated delirium,” “positional asphyxia,” “restraint asphyxia,” “in-custody deaths,” or “police use of force.” Furthermore, articles were excluded if they were not peer reviewed, not in English (due to translation limitations), or did not provide any of the following: 1) historical information on the origins of “excited delirium;” 2) a definition or description of “excited delirium,” which could include pathology or pathophysiology; or 3) a discussion of evidence supporting or refuting “excited delirium” as a distinct syndrome.

Between August 19, 2021, and October 20, 2021, the PHR team members read and summarized relevant non-peer reviewed material, consensus and position papers, secondary references, commentary, letters to the editor, and other literature, including the 46 peer-reviewed articles, in order to offer significant context.

The references and conclusions of these two separate literature reviews were consistently aligned and harmonious. In the initial phase of conceptualizing this report, a separate team from the PHR conducted a comprehensive literature review in July 2021 to ensure adequacy and coherence, and the findings were compared.


Our research focused on the use of “excited delirium” as a cause of death in police custody in the United States. We interviewed 20 experts on deaths in custody, such as forensic pathologists, forensic epidemiologists, emergency physicians, a certified medico-legal death investigator, plaintiff’s attorneys, prosecutors, and a law enforcement trainer. These interviews were conducted after receiving exemption from PHR’s Ethics Review Board. We utilized snowball sampling to connect with experts and continued reaching out until we achieved thematic saturation. The experts we interviewed came from various countries, including the United States, Canada, Chile, New Zealand, Italy, and Scotland. We also took into account the global impact of the medical literature on “excited delirium” by conducting interviews with forensic pathologists from outside the United States.

Doctors were interviewed to discover common ground and ongoing dialogue concerning “agitated delirium” and to gather information about their introduction to the term and the development of their comprehension. Lawyers were interviewed to provide background for the report and to obtain their perspectives on preventing deaths in custody attributed to “agitated delirium.” Additionally, PHR held discussions with experts in mental health and substance abuse crisis response, including personnel from the Treatment Advocacy Center, National Harm Reduction Coalition, Crisis Assistance Helping Out On The Streets (CAHOOTS), and Portland Street Response, with the aim of preventing these types of fatalities.

Attorneys were present for subsequent interviews, and PHR spoke with clients to determine whether any of their attorneys were interested in representing families in wrongful death lawsuits against law enforcement officers. We connected attorneys with civil rights connected to represent families who had lost loved ones in police custody, where “excited delirium” was designated as the cause of death. Finally, PHR received approval from the Ethics Review Board to interview PHR members who were family members of those who had lost loved ones in police custody.

Notes were also typed during the interviews. The interview was recorded, and all participants provided verbal consent to the interview. The interviewees were situated in various geographical areas, and the SARS-CoV-2 public health crisis necessitated conducting the interviews through video or audio conferencing.

Team members reviewed the written notes and transcripts to identify key themes across the interviews, using illustrative quotes. The interview materials and transcripts were securely stored on PHR computers. The interviewers used an interview guide that had been previously agreed upon by the research team. No compensation was provided to the interviewees for their participation in the interviews. The interviewees were given the choice to remain anonymous and use a pseudonym in this report. They were informed that their identity would be kept confidential unless they chose to disclose it, and they had the option to end the interview at any time. The interviewees were informed about the purpose and voluntary nature of the interview.


Instead of seeking to speak to both experts in the United States and internationally to gauge the ongoing discussion and consensus regarding the use of “excited delirium,” we decided to seek interviews with a variety of professionals in the field. These interviews include lawyers, physicians, emergency pathologists, and forensic experts, among others. It is important to note that these interviews are not intended to be a representative sample.

To examine references of the included articles, an exploration of context and history was conducted. After identifying and reviewing articles that met the inclusion criteria, a pragmatic research approach was adopted. It is possible that a comprehensive selection of relevant articles was not achieved, as the search was limited to only “excited delirium” and “excited delirium syndrome”. The medical literature review was not exhaustive and only one biomedical literature database, PubMed/MEDLINE, was utilized.


Beginnings and Historical Background

Key Definitions.

A syndrome comprises a collection of signs and symptoms that occur simultaneously and define a distinct abnormality or condition.[58] The etiology, pathophysiology, and/or progression of a “syndrome” are frequently not well understood. Once a definitive causative agent or underlying pathophysiological process is identified by medical science, the collection of signs and symptoms is then referred to as a “disease.” The classification of what is considered a disease evolves over time due to advancements in technology, diagnostic capabilities, and expert consensus determinations, among other factors. In the field of psychiatry, maladaptive mental and behavioral disturbances that impair functioning are often referred to as disorders. There are clearly defined criteria for diagnosing psychiatric disorders, although some have criticized these criteria for being unreliable.[59]
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) by the American Psychiatric Association provides a definition of delirium as a neurocognitive disorder characterized by a “disruption in attention and awareness that occurs rapidly and cannot be attributed to another preexisting, evolving, or established disorder.”[60] Additional symptoms may include decreased or increased activity levels and emotional disturbances such as fear, restlessness, or extreme happiness, as well as a diminished awareness of one’s surroundings. The exact cause of delirium is not well understood, but it is generally recognized as a manifestation of an underlying medical condition, such as organ failure, infection, oxygen deprivation, metabolic imbalances like low blood sugar, medication side effects, substance intoxication, or withdrawal. Treatment for delirium involves identifying and addressing the root cause, alongside supportive behavioral interventions and medical management including hydration, psychotropic medications, and pain relief.
Constraints in the medical setting are actively discouraged and avoided in the treatment of delirium, never include prone or neck constraints, and are monitored by an independent medical oversight organization (the Joint Commission on Accreditation of Healthcare Organizations). Delirium is not itself regarded as a cause of sudden death.

Bell’s Obsession

The rise in the diagnostic precision of psychiatric disorders and the effectiveness of antipsychotic medications has been attributed to the use of case reports between the 1950s and 1980s. These reports consistently describe the symptoms and signs of Mania Bell’s, which were previously labeled as encephalitis autoimmune or other diagnoses similar to bipolar disorder or schizophrenia. Before the description of Mania Bell’s, these diagnoses were referred to as “delirium,” “excited chronic delirium,” “lethal delirious maniacal acute mania,” or “delirium mania’s Bell.” The constellation of symptoms and signs in Mania Bell’s can result in death in some cases, with fevers, sleeplessness, hallucinations, transient delusions, and overactivity typically lasting for weeks to days. These cases primarily affect female psychiatric patients, as described by Dr. Luther Bell, a physician at the McLean Asylum in Massachusetts in 1849.

Wetli and Fishbain

The “medical nature” conceals the manifestation of delirium and concluded that treating delirium is essential in addressing the underlying illness. They mentioned that there are “two categories of delirium: stuporous … And excited” and explained that there are numerous potential causes that can be reversed and are temporary, and they characterized this “acute excited delirium” as a critical medical situation characterized by a disruption in attention and impaired perception. Wetli and Fishbain described the resulting delirium as a medical emergency characterized by a disruption in attention and impaired perception, and they co-wrote a case report about cocaine intoxication in an individual who ingested packets of cocaine to hide them inside their body, referred to as a “bodypacker.” In 1981, Wetli and Fishbain worked as a forensic pathologist and director of psychiatric emergency services, respectively, at the University of Miami. The credit for introducing the term “excited delirium” in the 1980s goes to Drs. David Fishbain and Charles Wetli.

According to a published case series by Fishbain and Wetli in 1985, there were seven cocaine users, six men and one woman, who exhibited unexpected strength and/or hyperthermia, hyperactivity, violent behavior, panic, and fear during a cocaine-induced psychosis. In some cases, the police had to restrain all of them, and they died suddenly with respiratory arrest, despite receiving assistance from bystanders and the emergency room staff.

Excerpts from Charles V. Wetli, and David A. Fishbain, 1985, “Cocaine-Induced Psychosis and Sudden Death in Recreational Cocaine Users,” Journal of Forensic Sciences, 30, no. 3 (July): 873 – 880.

No autopsies revealed the anatomical cause of death. However, in this publication by Fishbain and Wetli, it is described as a psychiatric presentation with a medical emergency called “excited delirium.” The prognosis depends on the underlying cause of delirium, as noted.

Fishbain and Wetli did not discuss the potential role that restraint may have played in the deaths of these victims. Instead of mentioning the prone restraint, they focused on other factors. They noted that seven out of the four individuals had their wrists handcuffed behind their backs, with their ankles fastened together using a strip of nylon, resembling a hobble. They were either hog-tied or had their feet and hands fastened together.

The initial conclusion drawn by Fishbain and Wetli is that the adjective “excited” is used to portray a hyperactive form of delirium. According to Lipowski, there are two major types of delirium: violent and hypervigilant, and agitated, panicky, fearful, hyperactive, shouting, and thrashing (excited), as well as apathetic, somnolent, mute, hypoactive, lethargic, and dull (stuporous). These descriptions of delirium were obtained from the same section written by Dr. Lipowski in the same edition of the Comprehensive Textbook of Psychiatry, where Fishbain and Wetli reviewed these pages. Both case reports from 1985 and 1981 are referenced in Fishbain and Wetli’s chapter in the 3rd edition of the Psychiatry PHR (pages 1359-1392).

However, there is no indication in his writings that Wetli had access to new scientific evidence underpinning this change, which will be discussed later as a unique disease and the cause of death, using the term “excited delirium” in a short time.

String of Homicides Targeting African-American Women in Miami

In the years that followed his publications on cocaine-induced “delirium,” Deputy Chief Medical Examiner Wetli began to search for new applications of his theories while working in Miami.

In November 1988 and September 1986, twelve African American females who were assumed to be involved in the sex trade were discovered deceased, consecutively, in the identical geographical region of Miami. Wetli and a number of his peers determined that nearly all of them had minimal amounts of cocaine in their bodies and categorized the majority of the fatalities as accidental due to cocaine poisoning. Wetli initiated the dissemination of his hypothesis on November 24, 1988, asserting that the women had perished as a result of combining sexual activities with cocaine usage, asserting that autopsies had definitively demonstrated that they had not been murdered.

Excerpt from Donna Gehrke, “Missed Calls, Close Calls Mar Serial Killings Case,” Miami Herald, April 26, 1990, page 1A. Highlighting added for emphasis. (Quote first published in Adrian Walker and Heather Dewar, “Cocaine-Sex Deaths in Dade Probed,” Miami News, November 24, 1988.)

Wetli hypothesized that during their time working as sex workers, women would ingest small quantities of cocaine, resulting in their demise due to sexual arousal. This phenomenon, according to Wetli, is the female equivalent of the “cocaine psychosis” he had previously discovered in males, where the male of the species experiences psychosis.

Excerpt from Donna Gehrke, “Missed Calls, Close Calls Mar Serial Killings Case,” Miami Herald.
Excerpt from deposition of Charles Wetli in Harrison v. County of Alameda, January 15, 2014. Courtesy of Julia Sherwin. Highlighting added for emphasis.

“[74] is deadly.” Speculated further he, without any scientific evidence, “We may discover that cocaine in conjunction with a specific (blood) group (more prevalent in individuals of African descent) is the potential reason behind the deaths of all the women who were African American.”

In the following month, he expressed, “We acknowledge that the deaths are linked to cocaine, but we still have limited comprehension of the mechanism.” [75].

Authorities did not start to consider them seriously until the toxicology report yielded negative results. However, it was only when Burns’ family opposed the theory for weeks that Wetli also became convinced that she had died from a mix of sexual activity and cocaine use, which was determined by the initial autopsy. 14-year-old Antoinette Burns was discovered deceased less than a month after Wetli began disseminating this theory on December 12, 1988.

In March 1989, investigators confronted Davis, the chief medical examiner supervisor, with evidence they believed pointed to Davis reexamining the case files of the homicides. They began to reexamine the case files to examine the evidence with which they believed Davis, without cocaine in her system, had died and the article that cited investigators’ beliefs that a serial killer was actually responsible for the deaths of Burns’ mother and the women. A newsweekly reported that the number of Black women found dead had reached at least 17.

The article described Wetli’s sex-cocaine theory for women as the counterpart of his “excited delirium” theory about men. “The women may be dying after sexual activity,” Wetli said. “The men just go berserk.”

“The men simply become uncontrollable,” Wetli stated. “The females might experience fatal consequences following sexual engagement,” Wetli’s hypothesis regarding women and cocaine-induced sexual activity is considered to be the equivalent of his theory on “excited delirium” in men. “We still have limited knowledge regarding the situation. However, my instinct suggests that this is a final occurrence resulting from prolonged usage of crack cocaine affecting the neural receptors in the brain. I believe it is a form of neural fatigue,” Wetli further advocated his belief that the combination of cocaine and orgasm leads to deadly outcomes.

He noted that in some cases of women’s asphyxiation, signs could be seen as clear as ten feet away from them. In those women’s cases, evidence of hemorrhaging in the eyes and pressure to the mouth in four cases, as well as evidence of pressure to the neck in seven cases, were found, which was enough to identify concrete signs of asphyxiation. Only nine women’s bodies had soon enough been identified with signs of asphyxiation. Initially, 14 cases that were left unclassified or ruled as accidents were later reclassified as homicides. Davis announced this conclusion, stating that 19 deaths of the women were all homicides, later that month.

Excerpt from the Metropolitan Dade County Medical Examiner Department’s amended investigation report for a woman found dead in October 1987. Her death had been ruled a cocaine intoxication accident in November 1987; Davis changed it to “homicide by inspecified [sic] means” in June 1989. Courtesy of Julia Sherwin.

The suspect, Henry Charles Williams, was identified by the police soon after he died on trial stand, later charged with one of the murders. It was eventually believed that he was responsible for as many as 32 women’s deaths since 1980, but he was arrested in 1989 for an unrelated rape charge. However, all of the women were believed to have been killed by the same individual.

“These girls were streetwise and, as a stimulant, cocaine can be lethal. I have trouble accepting that someone can kill without a struggle when they’re on cocaine… It is asserted that at least some of the women who died had a combination of cocaine and sex, and Wetli continued to assert this after Davis reclassified the homicides as deaths in the following year.”

Excerpt from Russ Rymer, “Murder Without a Trace,” In Health, May/June 1990, p.58. Highlighting added for emphasis.

[96]. “The reason behind this could be genetic,” why? While seventy percent of individuals who die from delirium caused by cocaine are black males, it is noteworthy that the majority of users are white. Wetli further propagated a related hypothesis regarding the death of black males due to cocaine-induced delirium, despite the absence of any scientific evidence to support it.

Excerpt from Russ Rymer, “Murder Without a Trace,” In Health, May/June 1990, p.55-56. Highlighting added for emphasis.

Wetli’s grave mischaracterization of the murders of Black women in Miami seemed to fail in discrediting his theory of sudden death from cocaine use, which equally gendered and racialized the concept of “excited delirium” as it grew, instead appearing to inform the presence of misogyny and racism.

TITLE Position Paper (2004)

Than a decade later, Wetli coauthored a position paper in the National Association of Medical Examiners (NAME) in 2004, which continued to discuss the assessment of cocaine’s involvement as the cause of death. The paper emphasized the need for a thorough review of medical information, forensic investigation, and autopsy to rule out any other obvious causes of death. It also highlighted the importance of considering the presence of cocaine metabolites in the body tissues or fluids, as well as the behavioral and clinical history of chronic cocaine use, in diagnosing “excited delirium” caused by cocaine. Furthermore, the paper mentioned that similar symptoms of “excited delirium” have been increasingly recognized in patients with mental disorders who are taking antidepressant medications, suggesting a potential catecholamine-mediated similarity between cocaine-induced and medication-induced delirium.

In its 2017 position paper, the decedent often exhibits erratic behavior due to acute drug intoxication and/or severe mental illness, resulting in a difficult observation of cases where individuals are defined as being delirious and excited.

Release of Enthusiastic Delirium Syndrome

Dr. Vincent Di Maio and Theresa Di Maio, a forensic pathologist and a psychiatric nurse respectively, introduced the term “Excited delirium syndrome” in 2005. They described it as the sudden death of an individual during or after experiencing excited delirium, where the cause of death cannot be determined through autopsy. They further defined “excited delirium” as a state of delirium characterized by aggressive or violent behavior, resulting from abnormal physiological reactions to stress. The Di Maios discussed the historical background and origins of “excited delirium” by summarizing case reports, primarily from the 1930s and 1940s, which mostly involved women in psychiatric institutions. In a 2014 deposition regarding a case of death due to restraint, Dr. Di Maio mentioned that he and his wife had coined the term “excited delirium syndrome”.

Studies on Restraint Prone

In litigation involving deaths that occurred while in custody, several individuals in this group, including Chan and Vilke, have connections with TASER/Axon and/or work as experts for the defense, creating a “cottage industry of exoneration.” According to an investigative report by the New York Times on December 26, 2021, Drs. Chan and Vilke are part of a “small but influential group of scientists, lawyers, physicians, and other police experts whose research and testimony is consistently used to absolve officers of responsibility for deaths.” Among the studies frequently utilized to defend law enforcement officials in cases involving deaths in custody are those conducted by emergency physicians Theodore Chan and Gary Vilke. While the Di Maios were promoting the idea of “excited delirium syndrome,” others were simultaneously researching the safety of prone restraint tactics.

This research study obtained approval from the Institutional Review Board (IRB) of the University of California’s Human Research Protection Program. They applied weights of 25 pounds and 50 pounds to the backs of ten participants, who were lying down. It is worth noting that the sample size was very small. The study was conducted by Chan and Vilke in the early 2000s. The authors concluded that the measurements of lung function, although statistically significant, were not clinically significant and showed a decrease of up to 23 percent. The study included only fifteen healthy volunteers, which is a small sample size and raises concerns about the validity and reliability of the results. In 1997, Chan and Vilke aimed to determine whether the “hobble” or “hog-tie” restraint position would lead to respiratory dysfunction with clinical relevance.

“He noted that we don’t want to put people on pounds 200 and kill them, as it would be unethical due to the possible danger. He seemed to suggest experimenting with greater weights, but stated that these were only preliminary studies. In his deposition, Vilke opined that the decedent was restrained in a prone position with weight placed on his back, referring to his studies involving the placement of pounds 50 and 25. Vilke served as the plaintiff’s expert in a case where a man with schizophrenia in a psychiatric crisis was restrained in a weighted restraint, resulting in asphyxia in 2001.”

“[114] Dr. Vilke, who testified in a deposition during the summer of 2021, reported to The New York Times that it was likely that an officer’s actions contributed to the death. He had been with the department for 20 years. [113] Even Vilke himself expressed doubt about whether it was Derek Chauvin, the Minneapolis police officer, who killed George Floyd by pressing his knee on his neck. [112] Vilke testified on behalf of the defense and stated that he always believed in the use of Tasers in cases involving their use. He also mentioned that he had worked as an expert defense witness for TASER/Axon International in a deposition back in 2018, acknowledging his involvement in several wrongful death cases against law enforcement and Axon TASER/Axon. After appearing in the Vilke case, he continued to work as a defense expert in other cases.”

In his 2014 deposition, Chan also acknowledged that he had retained a Taser in the defense of cases involving the use of it four or five times.

The study titled “Adults Healthy in Restraint Physical Aggressive During Demands Metabolic and Ventilatory,” published by Sherwin Julia and colleagues in 2007, reported that the authors received IRB approval from the University of California, San Diego, and the State of California. Despite the repeated efforts by Sherwin Julia to subpoena IRB-related materials, no evidence of completed IRB approval or related study materials was produced, raising concerns about whether this study has been used as evidence for safety. Furthermore, the study found no clinically significant impairments in ventilatory (breathing) function among the participants who were restrained in a prone position and vigorously struggled for 60 seconds. These participants, who were healthy adults weighing up to 225 pounds (102.3 kg), were restrained in a hogtie position on their backs.

In recent cases of death restraint handled by Julia Sherwin, both cases testified that officers restrained and beat the decedents in a prone position, putting weight on their victims’ backs, but it was not the choking that contributed or caused the deaths.

Function of TASER

Axon/TASER is a U.S. Company that develops technology for “less-lethal” electroshock weapons, commonly known as “stun” weapons. These weapons, including the Taser, are used by both law enforcement and the military. In 2007, approximately 1,000 to 1,500 copies of Maio’s Di book were purchased by TASER, ensuring widespread familiarity with his “excited delirium” theory in the forensic pathology community. It is worth noting that in the United States, there are only a limited number of full-time forensic pathologists, so the number of copies purchased in 2007 alone was sufficient to cover the entire community. Additionally, Axon/TASER distributed free copies of the book and provided other materials on “excited delirium” at conferences attended by police chiefs and medical examiners.

Maio Di, the acknowledged expert paid by Axon TASER, always stated his opinion that the Taser did not contribute to or cause the death of the person in the cases where he was deposed, and he testified multiple times.

Since there are only about 500 full-time forensic pathologists in the United States, TASER purchased enough copies of Di Maio’s book in 2007 alone to easily cover the entire forensic pathology community, ensuring widespread familiarity with his theory on “excited delirium syndrome.”

White Paper by the American College of Emergency Physicians (ACEP)

The leading journals in law enforcement and legal medicine will publish the findings from this seminal event, which focused on arriving at a “consensus” about IPICD law. The conference, advertised as the first IPICD conference, will help make history in the field of legal and medical enforcement law, with attendees excited about the conference’s focus on achieving a “consensus.” John Peters, an expert defense counsel for TASER, co-founded IPICD in 2005, along with Michael Brave, another TASER consultant and expert defense counsel.

Despite the close connections between the authors of the white paper, including Jeffrey Ho, the medical director of TASER, and Vilke, Mash, and Chan, the PHR TASER has been unable to find any disclosures or statements of conflict of interest in connection with the conference. The white paper, titled “Delirium Excited Syndrome: A Report on the IPICD 2008 Conference,” was published in September 2009 by the American College of Emergency Physicians. The conference included speakers such as Deborah Mash and Steven Karch, as well as consultants and experts in defense death restraint and TASERs, including Wetli, Vilke, Maio, Di, and Chan.

The Task Force on Delirium, in their report, elaborates on the various subtypes of delirium, including “hypoactive,” “hyperactive,” and “mixed” delirium. They recognize delirium as a clinical entity that is not aligned with the concept of “excited delirium” used by clinicians as the main diagnostic tool in the DSM-5 (Statistical and Diagnostic Manual of Mental Disorders). The authors assert that “excited delirium” cannot be considered the same entity as the forms of excitement or manic delirium listed in the ICD-9 (International Classification of Diseases, Ninth Revision) codes. They also indicate that the terms “excited delirium” and “delirium syndrome” do not provide similar codes in the ICD-9, suggesting a semantic issue. The authors acknowledge that there are no standard diagnostic criteria or tests for the syndrome of excited delirium, and the pathophysiology of this syndrome is not well understood, emphasizing the need for medical treatment.

Black men and “it may be genetic.” 18 years prior, Wetli had asserted without evidence that 70 percent of individuals who died from cocaine-induced delirium exhibited certain symptoms and signs that perpetuate racist stereotypes, such as “superhuman strength” and being “impervious to pain.” The White Paper Report outlines 10 specific indicators that suggest the presence of “excited delirium,” including high pain tolerance, agitation, unresponsiveness to police presence, extraordinary physical strength, rapid breathing, endurance despite physical exertion, inappropriate clothing or nudity, excessive sweating, elevated body temperature, and attraction to or destruction of glass or reflective surfaces. However, it does not provide any direct references to medical literature regarding the origins or accuracy of these indicators in predicting or diagnosing “excited delirium,” nor does it address the reliability of these indicators as a screening tool.

The authors published a reiteration of the White Paper Report in 2011, based on a review of the literature in peer-reviewed academic journals. The authors identified 10 features of “delirium” that need to be accurately identified in order to develop reliable screening tools for both non-diseased and diseased individuals. The authors also discuss the lack of disclosure or provision of conflicts of interest in the reviewed literature.

The findings and conclusions of the research reported here do not reflect the official position or policies of the respective organizations or the U.S. Department of Justice. It is important to note that the report was written by the director of NIJ, and the “Disclaimer” included in the report states that the state of extreme excitement, characterized by exceptional endurance and strength, extreme hostility, euphoria, hyperthermia, and extreme physiological and mental agitation, is defined as “excited delirium” by the National Institute of Justice in 2008.

The Passing of Martin Harrison

Harrison was placed in the jail’s general population without implementing any alcohol withdrawal treatment protocols. The LVN determined that Harrison did not require medical attention and sent him to the general population without implementing any alcohol withdrawal treatment protocols. He informed the licensed vocational nurse (LVN) who conducted the initial medical assessment that he consumed alcohol daily, had his last drink that day, and had a history of experiencing alcohol withdrawal. During the intake medical screening process, which took place around 3:00 p.M., Harrison appeared visibly intoxicated and had the scent of alcohol. A check for warrants uncovered an outstanding warrant for his failure to appear in court for a “driving-under-the-influence” charge, leading to Harrison’s arrest by the police and his subsequent transfer to the Alameda County Santa Rita Jail. On August 13, 2010, Martin Harrison was apprehended for jaywalking in Oakland, California.

Three days later, Harrison arrived at Harrison’s cell in jail, where deputies perceived him trying to shoot ten people because he was hallucinating, experiencing severe alcohol withdrawal or delirium tremens. He was forced into a prone position on top of officers, spit on, severely beaten, and Tased. Additionally, he had a hood placed over his head while holding a mattress over his head.

During Harrison’s stay in jail, no medical management was offered at any point, including his deteriorating medical condition, including his response to medical professionals, who considered his tremens and alcohol withdrawal to be treatable.

The defendants employed both Di Maio and Wetli as their expert testimonies.

“[146]. The argument is that Harrison’s death was caused by pure delirium, and it is suggested that someone may have experienced excited delirium in the presentation of Harrison’s case. An example of a classic death due to delirium and excited delirium is Harrison’s. Wetli and Maio Di state in their deposition testimony that Harrison died while experiencing delirium tremens. There was no dispute between the parties at the time he was restrained, Tased, and severely beaten – an incident which has been classified as an International Classification of Diseases code. In 2014, Wetli and Maio Di provided this testimony.”

Despite their claims about “excited delirium,” the depositions of Di Maio and Wetli affirmed these facts.

  • Delirium cannot be assigned a code as a cause of death or diagnosis, as there is no international classification of diseases (ICD-10 or ICD-9) for this specific purpose.
  • The fifth edition of the Statistical and Diagnostic Manual of Mental Disorders (DSM), which is currently in use in the United States, has never included the term “excited delirium” as a main diagnostic tool for mental health problems, according to health workers and physicians. [148];
  • “Agitated frenzy” is not acknowledged by the American Medical Association, American Psychiatric Association, or American Psychological Association.[149].
  • The Harrison case, which was settled in 2015, resulted in a trial that lasted eight weeks and led to changes in training and policies in the fifth largest jail in the United States. The settlement amounted to $8.3 million.

    “Excited delirium” has no International Classification of Diseases (ICD-9 or ICD-10) code, which means it cannot be assigned as a diagnosis or as a cause of death for statistical purposes.

    Review of Medical Literature

    The team at PHR explored the two main areas of controversy in the medical literature, which are the pathophysiology underlying “excited delirium” and the cause of death associated with “excited delirium”.

    Agreement in the Literature that the Pathogenesis of “Excited Delirium” Is Unclear

    The pathophysiology of “excited delirium” is not known, and there are no distinct or characteristic findings during autopsy, according to various reviewed articles. Many potential causes of the symptoms associated with “excited delirium” have been hypothesized, including disruptions in dopamine and/or dopaminergic pathways, a fight-or-flight response (surge in catecholamines) leading to cardiac arrhythmia, and asphyxia related to physical restraint or other forms of force. The overall quality of the studies is poor, and the levels of evidence supporting any proposed cause are low to very low, as concluded by multiple systematic reviews of the literature on “excited delirium.” Weaker forms of medical evidence, such as retrospective case reports, case series, or case-control studies, made up 65 percent (n = 43) of the articles, as discovered in a 2018 systematic review.

    Proposed Functions of Cocaine Intoxication and Neurochemicals in Manifestations and Indications of “Agitated Delirium”

    The term “excited” is initially used by al et Wetli to portray the hyperactive form of delirium in the context of substance-induced organic mental disorders. However, Dr. Zbigniew Lipowski does not use the term “excited” in his written chapter on delirium in the Comprehensive Textbook of Psychiatry. Therefore, the presentation of “excited delirium” is a secondary intoxication with underlying causes related to cocaine. The authors reported that “excited delirium” was included in the review articles by Fishbain and Wetli, which were part of the consensus among the articles included in the cocaine context.

    “According to Wetli et al. (1996), it is concluded that unless there is clear physical evidence, the cause of death should be attributed to cocaine, particularly in cases where cocaine users experience agitated delirium and death occurs due to mechanical or positional asphyxia, which is considered to be one of the mechanisms associated with delirium caused by cocaine.”

    Controversy remains about whether there is any evidence in the brain’s dopamine system associated with “excited delirium.” Some articles hypothesize that increased transport or release of dopamine leads to excited delirium, while others review the literature suggesting that cocaine interacts with different receptors in the brain’s dopamine system by increasing dopamine levels through various mechanisms.

    The mechanisms that lead to this cause of death have not been clarified, even though death from “excited delirium” in reviewed case series were frequently ascribed to acute dysfunction of the heart muscle resulting in cardiopulmonary arrest. Another proposed mechanism does not offer definitive proof for any one theory. Various medical conditions involving different neurotransmitters and pathways are also known to be involved. It is possible that a range of conditions may be associated with “excited delirium,” as suggested by other articles.

    Discussion in the Literature on Whether Prone Restraining Positions instead of “Excited Delirium” Contribute to Fatalities in Police Custody

    The decedent found themselves in a position that does not allow adequate breathing, resulting in positional asphyxia, as defined by Wetli and Bell [162].

    [164]. The odds of delirium diagnosis increased between times 29 and 7. Restraint was described as a form that excited all in 90 percent of deaths. They found that some form of restraint was found in all deaths described as excited delirium. They converted all relevant characteristics and case reports of agitated or excited delirium into a numerical dataset for quantitative analysis [163]. In the literature, Strommer et al. (2020) conducted an analysis and converted all relevant characteristics and case reports of agitated or excited delirium into a numerical dataset for quantitative analysis. They found that some form of restraint was described in 90 percent of deaths attributed to excited delirium.

    The outcomes of compression do not exhibit any distinct pattern, encompassing both positions that are vulnerable to restraint and attempts to recreate previous studies. Some reports have demonstrated that deaths in custody are unexpected and occur suddenly when prone restraint is employed. The physiological cause of death and asphyxia can be attributed to positional restraint, leading to a central debate on whether certain positions used for restraint have been associated with such incidents.

    During the restrained position, individuals took a longer time to recover from physical activity in a research that assessed the oxygen levels in the blood and heart rate. It was raised as a question whether this situation could be exacerbated during a violent altercation. Another investigation observed similar variables for various forms of physical restraint positions in overweight adults for an extended duration following exercise. The findings of this study indicated that there were no clinically significant effects, but the elimination of carbon dioxide was reduced in all restrained positions. None of the studies encompassed situations resembling encounters with law enforcement, where individuals may be struggling and agitated, as opposed to being at rest like the participants in these studies.

    Almost half of the adults suffering from chronic obstructive pulmonary disease were unable to complete the study that assessed the effects of prone positioning and restraint for 10 minutes due to uncontrolled respiratory symptoms. Other studies have demonstrated that applying weight to the torso of individuals in prone position resulted in reduced diameter of the inferior vena cava, blood flow, and/or cardiac output. Researchers have identified prone restraint positioning as a potential risk factor for sudden death, as it has been associated with significant decreases in lung function and other physiological parameters like heart rate and blood pressure. However, it remains uncertain whether these findings have any clinical significance, despite the statistically significant decreases in lung function measures observed during prone restraint positioning in certain studies.

    A 2020 study found that some form of restraint was described in 90 percent of all deaths in “excited” or agitated delirium. Restraint increased the odds of an “excited delirium” diagnosis by between 7 and 29 times.

    In comparison to the control position of arms by the side, the participants experienced notable and extended reductions in lung capacity over time, suggesting an elevated effort in breathing due to the cumulative effects of these circumstances. The scientists employed electrical impedance tomography (EIT) to assess the collective influences of these variables on ventilation in a group of 17 healthy individuals. A study conducted in 2021 observed that four key factors – physical activity, lying face down, restriction, and compression of the body – had been examined in previous research.

    The longer the weight is applied, the more relevant the posture restraint becomes in increasing the survival of the participant. It is hypothesized that in arrest-related encounters, an officer is less likely to apply weight to the body of the participant, as described in the study. The researchers noted that as the weight applied to the participant declined, the effort needed to breathe and the conditions in which they encountered arrest-related situations increased by 35 percent.

    None of the replicated studies accurately encountered someone “delirium” with police who may be struggling and agitated due to opposed restraints. Therefore, none of the participants in the study, who were agitated, fearful, intoxicated, or had mental illness, were forcibly restrained. These studies were primarily composed of healthy volunteers in well-controlled environments, with tiny sample sizes. All volunteers were placed in a mild and controlled position of restraint or placed in a prone position, and no measurable changes in respiratory and/or hemodynamic were detected in the above-mentioned studies.

    It is not known whether the use of forcible restraint, such as prone restraint, in conditions such as agitated person could significantly cause worse harms to respiratory or hemodynamic functions than what was found in these studies.

    Neck restraints should be classified as a form of lethal force, according to the American Academy of Neurology (AAN), for various reasons. A force equivalent to the average weight of a domestic cat or one-fourteenth the average weight of an adult male is required to compress the carotid arteries, as discovered in a 2009 study on different types of neck restraint.

    Can Delirium by Itself Result in Death?

    The DSM-5 recognizes delirium as a “disturbance of consciousness” characterized by a reduction in the clarity of awareness and attention, as well as a reduced ability to shift or sustain attention. There are three subtypes of delirium: hypoactive, hyperactive, and mixed. Some literature discusses that delirium cannot be the sole cause of death because it requires an identifiable underlying organic cause, which can be ascertained from diagnostic studies or the clinical presentation in autopsy cases.

    In their recent quantitative analysis from 2020, Strommer et al. Discuss the overlap between asphyxia-related risk factors and restraint-related risk factors, highlighting the characteristics that are likely to trigger the use of force and restraint in causing delirium in unrestrained individuals.

    Delirium alone cannot be a cause of death because, by definition, delirium requires an identifiable underlying organic cause that can be ascertained from the clinical presentation, diagnostic studies, or, in the case of death, by autopsy.

    Main Issues Addressed by Analysis of the Scientific Literature on “Excited Delirium”

    The foundations for the diagnosis of “excited delirium” have been misrepresented, with distortion and misquotation. The term was initially used by the authors to describe delirium and identify underlying causes. However, our analysis of peer-reviewed medical literature on “excited delirium” reveals that the articles supporting this diagnosis were authored by a small group of individuals, many of whom have affiliations with TASER/Axon and/or other conflicts of interest. These studies often refer to each other and draw conclusions that lack substantiation, relying heavily on non-peer-reviewed sources like the Di Maio and Di Maio book Excited Delirium Syndrome. A prime example is the repeated mention of Chan et al.’S 1997 study, which Di Maio and Di Maio describe as a decisive blow to the theory of positional asphyxia, dismissing belief in it as a suspension of common sense and logical thinking. They also claim that Chan et al.’S study “disproved” the hypothesis of restraint asphyxia. However, Di Maio and Di Maio’s conclusions are not supported by evidence. Chan’s single study, with a small and unrepresentative sample size that does not replicate real-life conditions, cannot deliver a “death blow.”

    During the postmortem examination, it is noted that asphyxia frequently does not exhibit distinct signs indicating the presence of a specific disease. It was discovered that restraint was mentioned in 90 percent of all fatalities documented in the medical literature on “excited” or agitated delirium. Strommer et al. Conducted a thorough analysis, which encompassed studies until April 2020, and provided a summary of all the characteristics associated with “excited delirium.” However, it should be noted that these studies have limited sample sizes and other constraints. The majority of the literature reviewed suggests a connection between “excited delirium,” death, and the use of restraint.

    We found no rigorous scientific research that examines the prevalence of death in people who are physically restrained and excited with “delirium”. Therefore, it is reasonable to hypothesize that these cardiopulmonary changes could become clinically significant and worsen in real-world settings. Although notable changes in cardiopulmonary parameters were observed even among participants in controlled and calm settings, it is unknown if these changes would be clinically significant in a specific real-world situation. All studies discussed here, including those that refute the claim of changes in respiratory and cardiac parameters, did indeed demonstrate measurable changes in respiratory and cardiac parameters, but they did not show significant clinically significant changes. Our review does not allow for conclusive determinations of the true cause of death, but it is most likely that the true cause of death for people who died from “delirium” excitement or restraint while agitated is positional asphyxia, not asphyxia from restraint.

    We found no rigorous scientific research that examines the prevalence of death for people with “excited delirium” who are not physically restrained.

    Analyzing over 230 scientific papers on restraints, body position, and “excited delirium” in the National Library of Medicine database, the authors of a December 26, 2021 investigation in the New York Times found that approximately 75% of the studies, which included at least one author connected to TASER/defense experts, consistently supported the notion that restraint techniques were safe or that deaths of restrained individuals were primarily due to underlying health issues. In contrast, only around 25% of studies conducted without any affiliation to the network endorsed this conclusion. More frequently, these other studies suggested that certain restraint techniques heightened the risk of fatality, albeit to a minor extent.

    Persistent Utilization of “Agitated Confusion” to Clarify Deaths in Custody and as a Legal Defense to Absolve Law Enforcement Officials

    The term “excited delirium” has been disproportionately utilized as a cause of death in cases involving young Black men, as discovered in a 2018 study. Taser utilization was linked to 47 percent of these cases. According to a search performed by a Berkeley professor of law and bioethics, out of the 166 reported deaths in police custody potentially due to “excited delirium” from 2010 to 2020, Black individuals accounted for 43.3 percent, while Black and Latinx individuals together represented at least 56 percent. A January 2020 report from Florida Today revealed that since 2010, Florida medical examiners attributed 85 deaths to “excited delirium,” with a minimum of 62 percent involving the use of force by law enforcement. An investigation conducted by the Austin-American Statesman from 2005 to 2017 exposed that more than one in six deaths (out of a total of 289) in police custody in Texas were ascribed to “excited delirium,” despite the issues associated with its diagnostic foundations.

    Families’ descendants have frequently brought civil lawsuits in defense against law enforcement officers who cause deaths related to restraint. However, prosecutions for murder, such as in the case of George Floyd, are not usually pursued against police officers. These prosecutions are notable exceptions. Additionally, the defense of causation delirium is often used by police officers who kill people during restraint, claiming that they were excited or agitated.

    Increasing Opposition from Medical and Psychiatric Associations in the U.S. Towards the Diagnosis of “Excited Delirium”

    The use of the term “delirium excited” should be ceased unless clear diagnostic criteria are established and advocated by both associations. Both available data and rigorous studies should be undertaken to establish a clear set of diagnostic criteria for “delirium excited”.

    “Excited delirium” is frequently asserted as a defense by police officers who kill people during the course of restraint.

    In June 2021, ACEP published a fresh task force report on “Hyperactive Delirium with Severe Agitation in Emergency Settings” without retracting the 2009 white paper. Meanwhile, the American College of Emergency Physicians (ACEP) has yet to amend its stance that “excited delirium” is a distinct form of delirium. The report acknowledged concerns about “potential bias” in the 2009 ACEP white paper on “excited delirium syndrome” and mentioned that since the publication of that report, “ACEP implemented a comprehensive global conflict of interest policy, although not specifically in response to critics of the 2009 white paper or with specific concerns about the content of that paper or others created prior to the implementation of such a policy.” The new report emphasized the importance of “distinguishing and treating life-threatening causes of hyperactive delirium,” outlined various potential underlying causes, and called for further research to “gain a more comprehensive understanding of the triggering pathways and distinct pathophysiology of individual causes of hyperactive delirium with severe agitation.” However, the 2021 report clarified that while its authors were “informed by” the 2009 report, the new report was created independently and should not be seen as an update or contradiction of the 2009 paper. Unlike the 2009 position paper, ACEP this time appended conflict-of-interest disclosures for the members of the task force responsible for this new report.

    Sandy Schneider, ACEP associate executive director, clinical affairs, affirmed that they support the findings presented in their ‘ACEP Task Force Report on Hyperactive Delirium with Severe Agitation in Emergency Settings,’ which was published on June 23, 2021. In response to PHR’s inquiry in February 2022, Sandy Schneider clarified ACEP’s current stance, taking into account their publications in 2009 and 2021.

    The American Medical Association and the American Psychiatric Association do not recognize “excited delirium” as a valid diagnosis and both advocate for cessation of the use of the term unless a clear set of diagnostic criteria can be established, rigorous studies undertaken, and data made available.

    The National Medical Examiners Association, equally concerned, has not publicly released a statement refuting the validity of the term “delirium” as a cause and diagnosis, in response to the attached papers referencing ACEP 2021 task force report and the current position of Dr. Kathryn Pinneri.

    Delirium, which is a well-recognized diagnosis in both the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) and the International Classification of Diseases (ICD), is medically referred to as acute hyperactive delirium. The term “excited delirium” is a descriptive term used to describe this condition, but it is not recognized as a diagnosis in the International Classification of Diseases (ICD-10) by the World Health Organization.

    A variety of injuries, intoxications, and diseases may result in acute hyperactive delirium, which can cause the underlying cause of death. It is important to note that delirium does not necessarily mean that the person was excited or hyperactive, although forensic pathologists may recognize this involvement in the absence of police presence. Deaths associated with acute hyperactive delirium may also have occurred without any external component.

    Paper position the support still do We, but this does not reflect our current position and the Certification on Deaths Cocaine-Related is no longer valid. The organization has never issued any consensus statement on excited delirium and it does not recognize it as a diagnosis.

    Global Scope of “Excited Delirium”

    Elsewhere, the deaths in custody of individuals in Canada, Australia, and the United Kingdom have also gained attention in the wake of “excited delirium.” While it has received widespread acceptance, the international spread of the term is concerning.


    “According to The Guardian, no Australian medical association recognizes the term ‘Excited delirium’. However, in certain instances of deaths in custody, Australian forensic pathologists have utilized this term. The Guardian has also highlighted a specific case within the past five years where TASER/Axon sent an email to law enforcement on the same day as a death involving Taser use. Although the forensic pathologist working on the case received the email from law enforcement, they chose to disregard it. The email emphasized its urgency with the phrase ‘TIMELY AND URGENT AND REQUIRES ACTION WITHIN 24 HOURS OR LESS’ and offered support for the investigation. Additionally, it extended an invitation to the police to submit brain tissue samples to the University of Miami Brain Endowment Bank for the purpose of determining drug abuse and identifying markers of excited delirium.”


    “[203]. The Royal Canadian Mounted Police (RCMP) issued recommendations in December 2007 stating that Tasers should not be used against the general public or individuals unless they pose a risk of serious bodily harm or death. This condition also applies to combative behavior, with the exception of individuals experiencing a unique condition known as excited delirium.”

    In June 2008, an independent review of the RCMP’s use of Tasers concluded that the term “delirium” should not be included in the RCMP’s operational manual unless it is formally approved by an advisory body on mental health policy and consultation with the RCMP. Additionally, the review stated that the term should be considered as “excited knowledge” by the police.


    The term “excited delirium” is not recognized by the European Society of Emergency Medicine, which represents physicians from 30 countries. The largest public provider of substance use and mental health services in the United Kingdom, the NHS Maudsley and South London Foundation Trust, also does not recognize the term ABD or “excited delirium,” as stated in a later addition to the Maudsley Prescribing Guidelines for psychiatric medications. The Royal College of Emergency Medicine in the United Kingdom issued guidelines in May 2016 for the management of “acute behavioral disturbance,” which also refers to what is commonly known as “excited delirium.”

    In 2020, the Royal College of Pathologists in the United Kingdom issued guidance for forensic scientists, noting concerns about the misuse and use of the term “Excited Delirium” as it should never be used to identify itself as the cause of death. The guidance also applies to police officers, who should be aware of the appropriate use of this term.

    Protesters marching in Aurora, CO over the killing there of Elijah McClain in August 2019. Photo: Michael Ciaglo/Getty Images

    The Passing of Elijah McClain

    [210] The forensic pathologist ruled that his death was undetermined, but it may have been a result of “excited delirium”. Four days later, McClain died in the hospital on his way in the ambulance, after going into cardiac arrest. Paramedics diagnosed him with “excited delirium” when they arrived and indicated that injecting him with an anesthetic, which almost doubled his weight, could be fatal. This occurred when he was unlawfully arrested, placed in a chokehold, and beaten while walking home from a convenience store in Aurora, Colorado, on August 23, 2019.

    There have been reports from whistleblowers who are paramedics, stating that they were pressured by police officers to administer ketamine even when it went against their professional judgment. In a July 2020 investigation conducted by KUNC, a public radio station in Colorado, it was discovered that over a span of 2.5 years, medics in Colorado administered ketamine to 902 individuals who were believed to be experiencing “excited delirium.” Unfortunately, about 17 percent of those individuals faced complications as a result. The killing of McClain also brought attention to the inappropriate use of ketamine by paramedics in response to perceived signs of “excited delirium.” The phrase “Justice for Elijah McClain” became a powerful statement within the Black Lives Matter movement, as it highlighted the unjust death of a young Black man who was simply walking home and was unjustly blamed for his own demise by law enforcement and first responders.

    The panel dismissed the designation or diagnosis of ‘excited delirium’ because it is prone to discriminatory practices that lead to systemic prejudice against communities of color, and because it lacks a consistent definition and specific, validated medical criteria. In December 2021, the independent ketamine review committee of the Colorado Department of Public Health and Environment released a report. In November 2021, the city of Aurora agreed to provide a settlement of $15 million to Elijah McClain’s family. In September 2021, a grand jury indicted three police officers and two paramedics for McClain’s death, charging them with manslaughter and criminally negligent homicide. In July 2021, Colorado Governor Jared Polis enacted a law prohibiting the use of ketamine by individuals without medical training and prohibiting its use in response to “excited delirium.” In June 2020, the American Society of Anesthesiologists issued a statement opposing the utilization of ketamine for law enforcement purposes.

    “The panel rejected the condition or diagnosis of ‘excited delirium’ because it lends itself to discriminatory practices that result in systemic bias against communities of color, and because it lacks a uniform definition and specific, validated medical criteria.”

    Colorado Department of Public Health and Environment, independent ketamine review committee

    The Passing of Daniel Prude [218]

    Following his sister’s account of his erratic behavior, Daniel Prude arrived at his brother Joe’s residence in Rochester, New York on March 22, 2020. Joe contacted emergency services when Daniel impulsively leaped down the stairs leading to the basement. Later that day, Daniel was discharged from the hospital. While under the influence of phencyclidine (PCP), Daniel departed from Joe’s residence during the late hours of the night. Joe made a second call to 911 and swiftly got into his vehicle in an attempt to locate Daniel. Upon the arrival of the police, Joe was instructed to return home or face potential arrest for violating the lockdown measures imposed due to the coronavirus.

    [222] “Do not murder my sibling,” Joe remembered informing him. And if he is unclothed, he poses no danger to anyone except himself. Joe informed the officer that the situation was under control. This marked the final statement Joe heard his sibling utter. Daniel replied “Affirmative” when an officer at the location inquired if he was Daniel Prude, as Joe overheard on the radio. Joe caught on the officer’s radio that they had discovered a man in close proximity, without clothes. Shortly after, a police officer from Rochester showed up at Joe’s residence.

    One week later, he was declared deceased at the hospital where he was transported. He remained unconscious and incapable of breathing independently after approximately 18 minutes of resuscitation attempts, Daniel’s circulation returned. Daniel regurgitated and became unresponsive while a second officer applied pressure to Daniel’s back, and a third officer restrained Daniel’s legs. He maintained that position for more than two minutes, while a second officer applied pressure to Daniel’s back, and a third officer restrained Daniel’s legs. One officer assumed a three-point “pushup” position with both of his hands on Daniel’s head, extending his legs out and concentrating his weight onto Daniel’s head. Upon sitting up, officers placed a spit hood over his head and face. Police body cameras captured officers chuckling while Daniel was on the ground. He lay face down, placing his hands behind his back, and officers placed handcuffs on him. When the officers located Daniel, they instructed him to lie on the ground.

    Joe exclaimed, “It required a whole week for me to uncover the fact that my sibling was receiving life-sustaining treatment.” A law enforcement official deceitfully informed Joe that his brother had passed away at the location of the incident, on the evening of the police altercation.

    One officer assumed a three-point “pushup” position with both of his hands on Daniel’s head, stretching his legs out and focusing his weight onto Daniel’s head. He held that position for more than two minutes, while a second officer put his weight on Daniel’s back, and a third officer held Daniel’s legs down. Daniel vomited and became unresponsive.

    On May 5, 2020, an autopsy report was issued by the medical examiner of Monroe County, describing the manner of Daniel Prude’s death as a homicide, caused by complications of asphyxia in a physical setting of restraint due to acute intoxication with PCP (phencyclidine) leading to excited delirium.

    In April 2020, the attorney representing the Prude family submitted a Freedom of Information Law request to obtain the video footage from the night in question, but city officials and the Rochester police chief sought to delay the release of the video, knowing that it would incite public outrage. However, they did not send copies of the video footage to the Prude family and his team until August [231].[230].

    Proceedings of the Grand Jury and “Agitated Delirium”

    “[235] In my opinion, none of the officers would have had any impact, collectively or individually, on the cardiac arrest that contributed to or caused their deaths. He told the grand jury that he wouldn’t have done anything differently than what the officers had done leading up to the cardiac arrest. Dr. Gary Vilke testified at the grand jury that Daniel died from PCP-induced delirium, which was excited by the cardiac arrest. [234] Vilke expressed doubt about the police officers’ responsibility for Daniel’s death, stating in multiple interviews that he was unaware of the “delirium, excited” condition. [233] The defense expert witness, Dr. Vilke, was retained by the prosecution’s office and testified about the “delirium, excited” state. [232] Letitia James, the New York Attorney General, announced that a grand jury would be empaneled to consider charges against the officers who restrained Daniel after the video became public in September 2020.”

    “This is something I’ve got to live with the rest of my life – seeing that video tape playing over in my head.”

    Joe Prude, brother of Daniel Prude

    “Reflecting on the anguish of losing his brother in such a manner, Joe acknowledged that he would have to carry this burden for the remainder of his life – the constant replaying of that video recording in his mind. The announcement of the grand jury’s decision not to charge the officers who restrained Daniel, which James found to be “extremely disheartening,” was made on February 23, 2021.”

    Training Suggestions and “Agitated Delirium”

    “The report released by the A.G.’S office acknowledged that the finding of false misconduct by the police that generated the shield was a Delirium Excited Syndrome (ExDS) that we are unaware of any peer-reviewed scientific studies endorsing. However, the report gave credence to the medical literature on Delirium Excited Syndrome (ExDS), stating that it can be controversial and the symptoms purported to overlap with racist stereotypes of Black men, which continues to put Black people in danger. The report also noted that it is important for medical personnel and emergency service providers (including dispatchers) and law enforcement officers to be trained to recognize and respond to Delirium Excited Syndrome (ExDS) as a serious medical emergency, as included in its recommendations. On the same day, the grand jury’s decision on Daniel’s death was also released.”

    “[241]. Training and protocols for responding to distress must be structured accordingly; when people display a unique constellation of symptoms that may signal imminent medical distress, EMS personnel, dispatchers, and law enforcement officers must be trained to recognize and respond appropriately. Instead of using the term “excited delirium,” which was removed from the Hodge Troy office’s investigation report into the 2019 death in custody, the office’s modified recommendations now recommend retaining the acceptance of the term “excited delirium” as a valid diagnosis. This decision came under media scrutiny in the wake of the report, with one month later.”

    The office of the Attorney General described this group of physical indications in the subsequent way:.

    Death is almost always attributed to acute drug intoxication or cardiac arrest. These individuals have become silent until they suddenly become quite intoxicated, and they have resisted the restraint and fought against it without seeming tired. In many cases, these individuals have often been involved in our cases while dressed in inappropriate clothing for the surrounding police restraints and/or existing weather conditions, or they have been highly sweaty. Generally, individuals have been summoned because of their erratic, violent, and bizarre behavior, indicating a sort of detachment from reality. The most commonly observed effect in these individuals involves the stimulant drug cocaine, which is the most common type of presentment in this office.

    Although this description appeared to be a re-packaging of some of the purported physical signs of “excited delirium,” the appropriately noted report highlighted the need for a coordinated response to medical emergencies.

    Nevertheless, the report also contained the cautionary note:.

    “[243]. Typically, individuals experiencing symptoms of fatigue and pain are largely impervious to them. However, when they struggle against it, they become particularly vulnerable to the rigor and stress of restraint. Our experience with cases under our jurisdiction has informed us that these individuals exhibit these symptoms. In contrast to the belief that restraint does not contribute to the death of individuals experiencing this condition, we are not suggesting that we are not addressing this issue.”

    The report importantly notes that while deaths were observed, PHR is concerned about the possible contribution to pathologizing the explanation above, which could potentially reinforce racist tropes using language that portrays a struggle as a normal and instantaneous human response (“restraint against”) and (“pain to impervious[ness]”).

    The Passing of Angelo Quinto[244]

    [246] Quinto passed away three days later while in the hospital. Bella and Cassandra then observed with shock and terror as the two officers pressed down on Quinto’s back for five minutes until he ceased to breathe. Quinto’s mother, Cassandra Quinto-Collins, heard him plead with the officers, “Please do not end my life,” on at least two occasions. When two police officers arrived, they removed Quinto from his mother’s embrace and placed him on the ground. On December 23, 2020, Bella Quinto-Collins dialed 911 in search of assistance for her 30-year-old brother Angelo Quinto, who was displaying restlessness and other indicators of a mental health emergency at their residence in Antioch, California. [245]

    Paramedics arrived shortly before Cassandra was recalled, and officers on his side turned to Quinto. They saw blood coming from his mouth and asked if Quinto had taken any drugs (247) [248]. Despite being unresponsive, Quinto did not receive CPR, which was observed by the officers. Cassandra reviewed the video recording of the officers’ actions in the PHR.

    Quinto was non-confrontational. The video recording validates this. Robert Collins, Angelo’s stepfather, stated, “Angelo was non-aggressive. He posed no danger to anyone. He complied with all instructions.” His mother affirmed that he did not consume methamphetamine. However, a subsequent toxicology report revealed the absence of methamphetamine in his system. The paramedics were instructed not to interact with the family. Law enforcement officers claimed that Quinto was under the influence of methamphetamine and confrontational, necessitating their restraint, as mentioned in the paramedics’ report. Cassandra attested to this.

    The police department obtained a felony warrant and searched the Quinto-Collins residence. The family was not allowed to reenter their home for eight hours during the time the search was being conducted.

    [254]. Cassandra had already shared the video, which they had copied until the police insisted that they should not let her leave the station. Outside, Cassandra heard him cursing and insisting that the police should not let her go. The police officer left the room and recorded the encounter when Cassandra recounted how the detective had visibly become disturbed while questioning her. She had not said that she had not had it. One of the officers asked Cassandra if Quinto had hit her because her nose was bloody. Cassandra and Bella were separately questioned that night at the police station.

    Cassandra and Bella recalled how law enforcement officers deflected responsibility for Quinto’s condition, sought to place blame on him or his family, and blocked the family from receiving health status updates from Quinto’s medical team.

    The family later learned that a detective at the Antioch police department had informed them about the hospitalization. However, they never gave the number to Cassandra, but the officer wrote it down. The officer then instructed her to turn off the phone and call back to ask for a number. Rushing over, an officer took the call on speakerphone. At one point that night, Cassandra received a call from Doctor Quinto at the hospital.

    [256] Bella and Cassandra recalled how law enforcement officers deflected responsibility for Quinto’s condition, seeking to place blame on his blocked family updates and medical care received from the medical team.

    The family learned that Quinto’s death, which was asserted by a forensic pathologist during a coroner’s inquest, was the official cause of death attributed to “Excited delirium syndrome.” However, it was not until August 2021, eight months later, that this information was revealed. [257]

    “Robert Collins, Angelo’s stepfather, recalled a previous meeting with the attorney’s family when he told us about his excitement and delirium.”

    Angelo Quinto (far right) with his family. Photo: Courtesy of the Quinto-Collins family

    Cassandra expressed, “‘Excited delirium’ must be discredited.” Continuously refuting the details of his demise, she discussed the immense pain of not only losing Angelo but also witnessing the actions of law enforcement. “We are already enduring immense suffering,” she stated. It was even more distressing to witness law enforcement “misrepresenting the truth about the incident.” [259].

    Angelo Quinto and George Floyd, who lost their lives due to the “knee to neck” constraint, are encompassed in the Angelo Quinto Act approved by California governor Gavin Newsom in September 2021. Robert Collins mentioned that the Quinto-Collins family initiated collaboration with the Justice for Angelo Quinto! Justice for All! Coalition following Quinto’s passing, advocating for both responsibility and modifications in the law. Their main concern was positional asphyxia and the response to mental health crises, aiming to hinder the occurrence of comparable events for others.

    A birthday vigil for Angelo Quinto on March 3, 2021. Photo: Courtesy of the Quinto-Collins family

    Main Topics Discussed in Interviews with Forensic Pathologists and Other Professionals

    Interviews were conducted with numerous physicians, as well as experts in legal matters, mental health, and substance use disorders, to explore alternative responses to individuals experiencing crises. The term “excited delirium” was employed to absolve law enforcement from blame in cases of deaths that occurred while in custody. This term was also used as a substitute for restraint asphyxia. There is a sense of hopefulness regarding the reduction in the usage of the term “excited delirium.” However, it is noted that this term lacks significance. Concerns were expressed regarding the validity of studies on prone restraint. TASER/Axon played a part in supporting and promoting the utilization of “excited delirium” as a cause of death. The initial attribution of “excited delirium” as a cause of death in Miami during the 1980s was proven false. Key themes were identified from interviews conducted by PHR with nine forensic pathologists and four other physicians.

    Discrediting the Concept of “Excited Delirium” Following Misclassified Homicides in 1980s Miami

    A number of forensic pathologists whom PHR interviewed were initially introduced to the term “excited delirium” through Wetli’s work in the 1980s. Dr. Michael Pollanen, the chief forensic pathologist for Ontario, Canada, and a professor of laboratory medicine and pathobiology at the University of Toronto, stated that Wetli’s original discussion of “excited delirium” took place during a period of increased cocaine use in the U.S.[262] He explained that it started as a “very classical clinical pathological description” of psychosis related to cocaine use and evolved into a cause of death. “The core concept remains highly useful, valid, and helpful, although it has been expanded too much beyond its original description,” he remarked. “Wetli eloquently described a series of cases that illustrated the concept of cocaine-related psychosis, which included symptoms such as high temperatures and muscle breakdown. It was a robust concept.” However, Pollanen noted that it has now been overly generalized as a cause of death, losing some of its original specificity.[263]

    [265] One of the individuals, Carter had conducted the postmortem examination for, mentioned that her period of study coincided with the office’s inquiry into the series of fatalities of African American women in Miami. Dr. Joseph Davis, the principal medical examiner, did not utilize the phrase, although Wetli frequently discussed “agitated delirium”. Wetli served as the assistant principal medical examiner in Miami from 1987 to 1989 during Dr. Joye Carter’s scientific fellowship, where she encountered the term. Dr. Joye Carter, the initial African American to be appointed principal medical examiner, is a forensic pathologist for San Luis Obispo County, California.

    “During my training period, I attended a monthly homicide meeting where all the homicide detectives and police agencies were discussing cases that had similarities. It was during this meeting that they realized they had a serial killer on hand. I remember being there while they were discussing the string of serial murders, which were initially classified as drug overdoses.”

    “You literally get this letter threatening you if you say Taser was the cause of death.”

    Dr. Joye Carter, forensic pathologist, San Luis Obispo County, CA

    She expressed, “I am of the opinion that this was discredited in Miami due to the manners in which these instances were managed,” right after departing the medical examiner’s office, Davis reassessed those instances. To put it differently, Carter stated, “This occurred to African-American males. African-American females were perishing as a result of engaging in sexual activity with African-American males.” Wetli had depicted the instances using expressions that were “highly influenced by race” and “divisive,” she remarked, alluding to his statement, “For some inexplicable reason, the male of the species becomes mentally unstable and the female of the species succumbs in relation to sexual intercourse.”

    “[267].” We initially attributed the string of homicides to Black women. Oh, we don’t even acknowledge the fact that death of Black women can be a cause of excitement-induced delirium. Those who promote the validity of this view said, “There was I.” We don’t even know the origin of “it,” let alone the origin of death caused by excitement-induced delirium. Other forensic pathologists have questioned Carter’s perspective.

    She expressed, “people within these groups tend to engage in behavior that is not only detrimental, which is why it has been discredited, but also stemmed from a specific origin and the notion of ‘excited delirium,’ which refers to a historical context. I genuinely believe that we need to explore this aspect.”

    The Role of TASER/Axon in Efforts to Validate and Enhance Use of “Excited Delirium” as a Cause of Death

    Interviewees described the efforts made by TASER/Axon to promote the diagnosis of “excited delirium”. Dr. Roger Mitchell, the chair of the pathology department at Howard University and a forensic pathologist, remembered first encountering the term in Di Maio’s book and later hearing it at an IPICD conference in Las Vegas when he was a young forensic pathologist. Several other well-known forensic pathologists who were interviewed also acknowledged Di Maio’s prominence in the field. Mitchell referred to him as a “pillar in forensics” and mentioned that, at that time, he was one of the most prominent and productive forensic pathologists. Dr. Michael Baden, a forensic pathologist and former chief medical examiner of New York City, recollected attending an annual meeting of the American Academy of Forensic Sciences where TASER had a booth and was giving away free copies of Di Maio’s book.

    [272]. “A major warning sign” was also noted in the TASER paper, which highlighted the numerous affiliations of the author. The paper described the findings of lethal toxicity without any clear biological mechanism. The author stated that it is not just a collection of symptoms, but it requires further work to clarify the agenda. However, it is evident that there is a lot more work needed. There appears to be a resemblance to junk science, with a lot of symptoms that seem like junk. It seemed like a lot of junk science. It appeared to be junk science. It seemed like a lot of junk science. It appeared to be junk science. It seemed like a lot of junk science. It appeared to be junk science. It seemed like a lot of junk science. It appeared to be junk science. It seemed like a lot of junk science. It appeared to be junk science. It seemed like a lot of junk science. It appeared to be junk science. It seemed like a lot of junk science. It appeared to be junk science. It seemed like a lot of junk science. It appeared to be junk science. It seemed like a lot of junk science. It appeared to be junk science. It seemed like a lot of junk science. It appeared to be junk science. It seemed like a lot of junk science. It appeared to be junk science.

    Dr. Judy Melinek, CEO of PathologyExpert Inc. And contract forensic pathologist for Communio Inc. In Wellington, New Zealand, pointed out that no one desires to be taken to court. She also acknowledged the impact that these lawsuits have on medical examiners, describing it as a “silencing effect.” Carter stated that medical examiners are being directly threatened with legal action if they state that Taser was the cause of death. In fact, they receive a letter that explicitly threatens them. Several forensic pathologists have mentioned the alarming consequences of TASER/Axon’s lawsuits over the years, specifically targeting medical examiners who have linked in-custody deaths to the use of Tasers.

    Doubts regarding the Credibility of Studies on Prone Restraint

    According to the given information, the reversed paragraph would be: “[277] “That specific type of scientific research was created for the purpose of providing legal support, aiming to safeguard law enforcement officers who might have been involved in the accidental death of an individual they were restraining,” he stated. “[276] Dr. Michael Freeman, a forensic epidemiologist and associate professor of forensic medicine at Maastricht University in the Netherlands, criticized the studies as “clearly unscientific research that suggests it is practically impossible to cause someone’s death through restraint.” Numerous forensic pathologists and other medical professionals expressed doubts regarding the reliability of the studies that Vilke and his colleagues utilized to support their claims that restraint is not hazardous.

    Others emphasized the artificial conditions of the studies, which involved healthy, non-stressed participants, as noted by Dr. Kris Cunningham, the deputy chief forensic pathologist for Ontario, Canada and a cardiovascular pathologist.

    “[278]. It is an extremely contrived scenario. Well, that is fantastic, but you are also not experiencing any discomfort or distress due to a law enforcement officer being present behind you. And, to everyone’s surprise!, They do not experience a lack of oxygen. There are numerous issues with several of the research projects conducted in the past, in which they gather a group of medical students and place them in a face-down position while restraining them.”

    Pollanen also highlighted the contrasting circumstances in these studies compared to real-life situations.

    “How physiologically or medically comparable is the demand for high oxygen stimulation in someone whose maximal adrenergic response occurs while in a prone position under restraint? The problem of asphyxia during restraint is critiqued as a significant issue in the majority of experiments conducted on ambulatory healthy individuals.”

    Absence of Significance of the Phrase “Excited Delirium”

    (281) [Pollanen] perceives it from a critical perspective” “an unfortunate jumble of ideas when you, [Cunningham] exceedingly vague concept” “a extensively overused term that we don’t genuinely comprehend” (Dr. Jared Strote, an emergency physician and professor of emergency medicine at the University of Washington), Others characterized “excited delirium” as (280) [Freeman] a factor leading to death.” Anything as a label. It is a fabricated term.

    Pollanen posited that this summary description should not be used for any causal conclusions, but rather as a short, abbreviated form of an excited delirium behavioral series, which consists of a variety of features.

    In the field of medicine, we frequently engage in this practice. We utilize that and discover denoting terms that portray something. Typically, we do not attribute causal significance to it when we engage in this practice within medicine. It is simply a shortened form. However, if you were to attribute causal significance, such as it being a potential cause of death, the issue with ‘excited delirium’ arises as there is no means of distinguishing an individual with ‘excited delirium’ from someone who is simply highly agitated. The problem persists in that there is no way to differentiate between an individual with ‘excited delirium’ and someone who is merely highly agitated, if you were to attribute causal significance. We frequently employ that and discover denoting terms that describe something. This is a common occurrence in the field of medicine.

    Canada, Alberta, Edmonton has a medical chief deputy named Dr. Enrico Risso. He describes a controversial theory that explains the common final path triggered by different substrates resulting in an increased level of catecholamines. This theory is described as a generic term that applies to the confluence of symptoms. Others describe it as a term that describes the term in a generic manner without supporting evidence. The concept has evolved in an inappropriate manner, progressively modifying the whole thing. Therefore, the use of the term “almost as delirium” to describe the excited state is considered an error in nomenclature, as stated by Pollanen.

    “[285],” Chenevert said, “it can’t just see death as the primary cause. The majority of the interviewed experts held the view that delirium should not be considered as the sole cause of death. Regardless of their views, the signs and symptoms of this particular constellation should never be used to describe excited delirium.”

    Positivity regarding the Reduction in the Usage of the Phrase “Excited Delirium”

    In the past few years, the term “excited delirium” has been losing popularity, and many forensic pathologists and other doctors have become hopeful. According to Cunningham, this concept is now seen as “more appealing in the past.”

    “[288]. In the 21st century, we now understand that delirium is not a suitable cause of death for all things. ‘Excited,’ said Pollanen.”

    Respondents have speculated about possible reasons that may be used less frequently. Mitchell’s research cites the need for the forensic pathology community, particularly in the medical community, to obtain more information in order to adjust and avoid being dogmatic in our diagnosis.

    Mitchell provided further details on this potential clarification:.

    “[291] People are not scared to say what they’re seeing, as eyewitnesses… We have video footage from cellphones in 2021. It’s an altercation…. Yes, an individual may have been intoxicated, but he would have gone home. Imagine five physically grown men subduing an intoxicated individual. Now, we’re seeing the actual footage of what is happening, standing on people’s backs. They’re dead and shaking, and they started self-combusting. If someone is saying we are as if they have objective evidence of the severity of the altercation with the police, we didn’t have direct evidence. We didn’t have cameras when that diagnosis was used. It’s a different world.”

    The entire range of the death display, involving physical restraint and agitation, along with cocaine use, was described by Martinez as a single diagnosis for the man’s death. Risso stated that the majority of cases do not have provable underlying pathological findings and that they prefer not to describe them during autopsies. Martinez, a forensic pathologist from Chile’s Legal Medical Service, and Risso agreed that they did not object to using the term “delirium” to describe the excited state, even though other forensic pathologists they interviewed did not use it.

    “Then you have preexisting conditions,” clarified Carter. “I would prefer to explain the medical condition rather than categorize it as a syndrome like excited delirium,” stated Mitchell. “For instance, it could be a case of physical injury with sudden cocaine poisoning during police restraint. It depends on the specific circumstances,” stated Cunningham when determining the cause of death. Other forensic pathologists also stated their preference for providing a detailed account and referencing the underlying illness or circumstances. “I have been more explicit in describing my discoveries,” Mitchell added.

    “‘Excited delirium’ as a cause of death is not fit for purpose in the 21st century, based on all the things we know now.”

    Dr. Michael Pollanen, chief forensic pathologist for Ontario, Canada

    The Utilization of the Phrase “Excited Delirium” as a Substitute for Restrained Asphyxiation

    “[298] He stated: “Remove the limitation, what are the likelihoods that the circumstances existing in the controlled person result in his death at that specific moment?” Drawing from the field of epidemiology, he suggested that one should examine deaths attributed to “excited delirium” by considering counterfactual causation. As Freeman stated, “The evidence suggests that it is misused or unknowingly substituted for asphyxia caused by restraint.” Numerous forensic pathologists and other doctors expressed their disapproval of using “excited delirium” as a substitute for asphyxia caused by restraint in encounters with law enforcement.”

    “If the enforcement law is applied, you cannot be restrained from killing, as the theory that leveraged absurdity is due to the drugs they took and it’s the fault of the decedent’s sudden death causes. This is a unique pathophysiologic process that is characterized by the unique process of ‘excited delirium,’ but this hypothesis is unproven.”

    “Many forensic pathologists interviewed linked the use of the term ‘excited delirium’ with certain actions such as restraint, prone positioning, neck compression, and chest compression, which could cause asphyxia.”

    [301] “If cocaine is present, it remains an outcome of asphyxiation caused by restraint,” Carter stated, but the individual would not have perished if the restraint was not applied, “In my opinion, let’s refer to it as it truly is.”

    There is already a restraint on their stress. However, Strote also noted that a person who is agitated and under stress can have an increased risk of death when restrained, due to the hyper-adrenergic state of their heart and the release of adrenaline. In the interview, one of us referred to the possibility of the patient dying more likely from an “excited delirium” than from the restraint. Freeman described both the possibility and uncertainty at a specific point in time, stating that the oxygen needs of a restrained person are variable and unknown. The forensic pathologists interviewed also noted that a person exhibiting physical signs attributed to “excited delirium” would have a heightened risk of death when restrained, but it is still unknown.

    Cannot use an example from forensic pathology to illustrate the responsibility of death and cannot use conditions that predispose the perpetrator to mitigate the responsibility of death.

    “A cause of death that can only happen at the hands of cops is not a pathophysiologic process, but rather a semantic ploy designed to immunize police against scrutiny of deaths occurring during restraint.”

    Dr. Michael Freeman, forensic epidemiologist and associate professor of forensic medicine, Maastricht University

    Utilization of “Agitated Delirium” to Clear Law Enforcement of Fatalities in Custody

    Some doctors observed the widespread occurrence of “agitated delirium” as a term used to excuse police shootings. Freeman stated:

    “[305] Restraint during instances of police scrutiny is not a process pathophysiologic but rather a semantic ploy designed to immunize against deaths occurring at the hands of cops. The possibility that police caused the death is taken into consideration because it allows us to ignore the term that extreme use of force is how no matter.”

    Pathologists and police officers began using the term ‘excited delirium’ to describe potential cases of homicide where restraint can cause clear evidence of death, as expressed by Strote.

    “[307].” Remarked Baden, “It is almost always due to a unique medical condition or disease if you experience a struggle between civilian and police officers during which death occurs,” Baden noted, “other forensic pathologists have emphasized the implications. The term ‘excited delirium’ is primarily used as a cause of death for deaths that occur in police custody.”

    Lack of Uniform Standards for Death Investigations

    There is currently no federal oversight for medicolegal death investigations and forensic pathology accreditation in our country. Our goal should be to ensure uniformity in the practice. We need a system that is not influenced by organizations run by politicians or sheriffs, but rather by pathologist-run organizations. This is the current situation, where each state, city, and county has its own construct.

    Enacted in 2013, the Death in Custody Reporting Act has not produced any report or information, as required by law. My proposal is to include a checkbox on the standard death certificate in the United States, which would enable physicians, who are responsible for certifying deaths, to identify cases of deaths in custody. It is crucial to have an unbiased way of measuring deaths in custody, and this should be done by physicians, in addition to the circumstantial data provided by law enforcement agencies.

    Defining deaths in custody as a public health issue… It is time for the public health infrastructure… Then, we need to know how to construct a public health problem… Then, there needs to be reviews to address the problem of death-in-custody fatalities.

    – Dr. Roger Mitchell, head of the pathology department at Howard University.

    Suggestions for Different Approaches to Individuals in Distress

    Many interviewees, including mental health experts, lawyers, and physicians, emphasized the need for individuals to respond differently in different kinds of emergency crises.

    Revisions in Police Protocols and Emergency Response Procedures

    According to Strote, the goal of an emergency response should be to maximize the protection of others and minimize harm to the person involved, by placing individuals in a position of recovery or avoiding a prone restraint. Some training programs for police focus on the specific details of this need.

    “Is there anything in our protocols that requires modification?” Melinek emphasized while delivering her lectures. “This presents another chance to inquire: if the forensic pathologist claims that your actions have resulted in the death of the patient/individual,” she asserted. “In numerous instances, law enforcement officials are not educated or adequately trained on the potential fatality of employing a carotid hold,” she advocated for alterations to police protocols.

    As quickly as possible, the individual should seek medical assistance. The goal is to have EMS dispatchers coordinate a comprehensive response, utilizing various disciplines, as they are skilled in identifying indicators of a medical emergency in a person. Jack Ryan, a former captain of the Providence, Rhode Island police department, who presently provides training for law enforcement and conducts audits of their policies and procedures, suggested that dispatchers and other first responders should have further discussions regarding enhanced training and protocols. This would enable them to deploy suitable resources, other than or in addition to the police, in response to emergency calls. This necessity was also raised by other individuals interviewed.

    “[311]. EMTs often prefer soft restraints instead of hard mechanical restraints to immobilize individuals. Instead of restraining someone on a gurney, they may choose to hold them down on their stomach. It’s important to remember that you can restrain somebody on a stretcher.”

    “[312] Occasionally, there are drug-induced crises, as well as medical and mental health crises. It is important to keep in mind that the symptomology of these crises can vary across individuals. Therefore, we should ensure that our trainee officers are well-equipped with the necessary knowledge and skills to handle such situations. Instead of resorting to physical force, such as putting pressure on someone’s neck or knee, we should focus on stabilizing the situation and seeking medical assistance. Additionally, we should strive to reduce the duration of these struggles and ensure that we have sufficient resources in place. Can we develop a similar plan for dealing with these different types of crises, as suggested by him?”

    Ryan also mentioned that officers should be trained to avoid putting weight on the back of an arrestee once they are handcuffed and in a prone position, as this helps facilitate their breathing and allows them to sit or turn on their side.

    “I think we should have a better system where all these people don’t fall into the hands of law enforcement. It is disheartening to see people stuck in jail because there is no other place to go. I do some audits of jails. They say LA County Jail is the largest mental health institution in the US. Law enforcement has become a catchall at the end of the day. We know that de-institutionalization has led to some issues beyond law enforcement.”

    Medical and Behavioral Health Emergency Teams and Support Networks

    “In an emergency medical situation, the worst thing you can do is force someone against their will. They don’t need to be coerced or compelled to receive medical treatment. It is argued that when encountering the police, someone in a state of medical emergency may claim that they need assistance, and currently, law enforcement is obligated to respond to many requests for medical help. This is a civil rights issue that Dale Galipo, an attorney, agrees with.”

    “He emphasized the limits of seeking to improve police training in order to respond to behavioral and mental health crises, stating that we should consider it our responsibility to be more responsive, different, and better in doing something for society. He also pointed out that police officers, who are not positioned best to respond to a mental health crisis, may inadvertently violate the civil rights of individuals. He categorized these violations into two primarily seen groups: civil rights violations and law enforcement injuries and violence. Jim Davy, a civil rights attorney, observed that the majority of these violations and injuries are a result of police officers not being explicitly trained to do the right thing and to not do the wrong thing. He further emphasized the need to improve police training in order to effectively respond to mental and behavioral health crises.”

    PHR consulted with Portland Street Response, Crisis Assistance Helping Out On The Streets (CAHOOTS), Treatment Advocacy Center, and the National Harm Reduction Coalition to gain insight into alternative models. In March 2021, a federal law allocated $25 million to states to aid non-law enforcement mobile crisis teams.

    Dr. Kimberly Sue, the medical director of the National Harm Reduction Coalition, provides drop-in spaces in Seattle and San Francisco, including the People’s Harm Reduction Alliance and the Sobering Center, to support people experiencing the effects of substances other than methamphetamine and to offer alternative spaces for people in substance use crises.

    What is being overlooked is the fact that every day, individuals with untreated mental illness live in crisis, posing an imminent threat to themselves and their loved ones. To prevent these crises and support the families in need, there should be a focus on building an adequate mental health system and providing proper support. Muhammad Sabah, a policy and legislative attorney at the Center for Advocacy and Treatment, spoke about the need for police forces to empower and help families in getting treatment for their loved ones, using involuntary commitment statutes as a last resort option. The report by the Center for Advocacy and Treatment in September 2020 found that seven states have laws in place that recognize the potential life-threatening nature of these situations.

    “Something can be established that resembles long-term treatment… Because when you simply idle and anticipate a crisis, you are essentially anticipating entire communities to endure until they are going to be injured or perish,” Muhammad stated. She conveyed optimism that the more frequently clinicians and social workers are integrated into these frameworks, the more families can avail themselves of comprehensive services or relationships of confidence. Regarding the various frameworks, she mentioned, “All of them are in an early stage. And they are highly dependent on the state. If certain frameworks prove effective in one region of the country, they may not necessarily be effective in another.” Hancq categorized crisis response models into three types: Crisis Intervention Teams (CIT, response based on law enforcement), co-responder teams (response based on law enforcement and mental health), and mental health crisis teams (response based on mental health).

    “[324] The following course of action for them would be to notify law enforcement, preferably a social worker, doctor, or clinician who has received crisis training or medical training. If there is a weapon involved, they can become part of the team. Muhammad emphasized that it should not only be the police who respond first, but if the situation requires it, it should also involve emergency personnel.”

    “[325]. It should be ensured that something is done to preserve the life of the individual. This is something that should not be done quickly. It takes time to realize that someone is in the midst of a hallucination or delusion, and we are missing out on many opportunities to be able to tap into our humanity,” she explained, “to be reasonable.”

    [326]. According to him, resources such as harm reduction and street medicine, homeless outreach, violence interruption, 24-hour access to mental health resources, food access, hygiene, and shelter could be included. He mentioned that there is not much discussion about “rapid access and connection to those resources,” but it is widely discussed and popular to talk about mobile crisis [programs]. He added that crises are “directly linked to some unmet need” because it is more important for the community to strengthen the social safety net rather than “bringing in mobile crisis teams” due to limited resources. Tim Black, the director of consulting at the White Bird Clinic, which operates the mobile crisis intervention program CAHOOTS in Eugene, Oregon, emphasized that any type of mobile crisis system should first be informed by the community and then by providers.

    The White Bird Clinic further noted that the clinic is open to recruiting and training team members who have a variety of educational backgrounds and life experiences. Instead of requiring workers to be licensed health or mental care professionals, the clinic aims to create opportunities for staffing positions in smaller communities, especially in response to crisis situations.

    “[329] Black concurred that there is no singular prescribed method of funding that is effective for every community.” She stated that the “shared element” present in all of these models is the requirement for funding channels at both the national and state levels, which provide the necessary flexibility to accommodate various models. Robyn Burek, program manager at Portland Street Response, revealed that she has engaged in discussions with “approximately 100 different cities” regarding their approaches to mobile crisis response. “Each city has a slight deviation in their operational methods, and I find that truly remarkable.”

    Legal Structure

    Law in the United States

    Acceptance of “Euphoric Delirium” as a Diagnosis in U.S. Courts – Despite Lack of Agreement on its Definition

    Despite significant challenges, the term “delirium’s” has been admitted as a legitimate diagnosis in U.S. Courts, limited to a specific context in which death is the direct cause. It appears that the term is limited to cases involving interactions between individuals and law enforcement, indicating that its validity within the medical community is excited for legal review.

    Given the lack of a clear definition of the term “excited delirium” found in legal cases and diagnostic manuals, it can be considered a reasonable medical diagnosis for a police setting. It might be described as yelling or incoherence, hyperactivity, delusions, confusion, and bizarre behavior. Although it is often associated with drug use, it is not necessarily always the case. It is broadly defined as a manifestation of almost every drug-induced or psychiatric behavior that can be observed. It has even been described by courts as including imperviousness to pain and superhuman strength. It is also often described as being initiated by physical stress or brought on by an underlying history of mental illness or drug use. One court even found excessive sweating to be indicative of “excited delirium”.

    Acceptance of Expert Witness Testimony on “Agitated Delirium”

    The admissibility of expert testimony is determined by whether the theory has undergone peer review and publication, and if it has gained widespread acceptance in the relevant scientific community. When evaluating “excited delirium,” courts consider important factors such as the scientific validity of the expert testimony’s underlying methodology and its applicability to the facts in question. Both federal and state courts conduct a preliminary assessment to fulfill their “gatekeeper” role, ensuring that the expert testimony meets the necessary scientific standards.

    Arguments against the theory that evidence should be admitted in court based on the persuasiveness of finding evidence as “excited delirium” often rely on the fact that plaintiffs in cases seek to exclude testimony on “excited delirium.” Many police departments train their officers to interpret people’s behavior through a lens that assumes many mental or medical health conditions are “excited delirium.” Additionally, forensic examiners, pathologists, and physicians from the American College of Emergency Physicians generally accept “excited delirium” as a diagnosis, pointing to three communities where this is the consensus. The technique or theory of “excited delirium” has also been subjected to peer review and published, allowing its admission in court. Finally, the white paper from ACEP cites the distinctive behavioral and clinical characteristics of a specific group, which can be identified as the “excited delirium syndrome,” resulting in a consensus described even by the court.

    The World Health Organization or the American Psychiatric Association, as well as the American Medical Association, do not recognize “excited delirium” as a medically diagnosed condition in either the Statistical and Diagnostic Manual of Mental Disorders or the International Classification of Diseases. Even expert testimony in courts has admitted this, notably.

    The persistence of “delirium” in academic literature on conflicts of interest and embedded citations demonstrates troubling reach and poor quality, despite its homogeneous nature. The harmful impact of ACEP’s 2009 white paper on the acceptance of “excited delirium” is also underscored by U.S. Courts, which have yet to refute it.

    Utilization of “Excessive Agitation” as a Justification for Officer Behavior

    The admission of the “excited delirium” theory as evidence in courts, particularly in civil rights cases involving allegations of police brutality or wrongful death, has also been utilized by law enforcement defendants. This has resulted in a lack of accountability for law enforcement officers who cause fatalities during the course of restraint by claiming that the deceased individual died as a result of “excited delirium.” Some courts have used the expanding defense of qualified immunity to protect these officers from consequences. By associating the individual diagnosed with “excited delirium” with notions of being impervious to pain or possessing superhuman strength, the force used by law enforcement when dealing with such individuals may be considered reasonable instead. Deaths that could otherwise be attributed to asphyxiation caused by excessive force may instead be dismissed as natural or accidental due to the victim’s “excited delirium.”

    Influence of the Ubiquity of “Agitated Delirium” in Police Training

    By introducing evidence that officers failed to follow trainings in this manner, attorneys validate the protocols of law enforcement and perpetuate the acceptance of the term “excited delirium” in courts at the expense of future victims of police violence. In fact, even the defendant officers should have recognized that the decedent plaintiff, who was experiencing “excited delirium,” exhibited hallucinations, aggression, bizarre behavior, and great strength, and was impervious to pain. It is a fact that a number of lawsuits against police officers for mishandling and violating the unique medical needs posed by “excited delirium” have resulted in the pervasiveness of this term within training manuals and law enforcement policies.

    Law enforcement policies and training manuals outline several potential dangers associated with the widespread occurrence of “excited delirium.” Some law enforcement agencies or trainers classify conditions such as heart attacks, drug or substance abuse, withdrawal symptoms, oxygen deprivation, and acute psychosis as part of the “excited delirium” diagnosis. However, in emergency situations, these conditions may require different medical interventions than what is typically recommended for “excited delirium.” For example, the case of Petro v. Town of West Warwick revolved around whether the officers failed to provide prompt assistance, with the key issue being whether Mr. Jackson died from “excited delirium syndrome” or sudden cardiac arrest caused by untreated primary cardiac disease. In Estate of Hezekiah Harvey v. Roanoke City Sheriff’s Office, the defendants’ expert, who was the assistant chief medical officer of West Virginia, determined that Mr. Harvey’s cause of death was “excited delirium due to chronic schizophrenia,” with congestive cardiomyopathy as a contributing factor. Consequently, the defense argued that it was irrelevant whether emergency medical personnel administered antipsychotic medication to Mr. Harvey, who had schizophrenia.

    When law enforcement officers are not held accountable for their actions, it is doubly harmful as the justice system not only prevents accountability but also lacks a real basis for medical diagnosis, thus undermining the underpinning of Human Rights for Physicians as explained in a brief to the United States Supreme Court.

    Under the civil action of § U.S.C. 1983, often the only way to vindicate the rights of a victim of official misconduct is by proving their case, even though qualified immunity often bars those plaintiffs who can prove no wrong, harm, or violation of their legal obligations to sidestep federal law and enable public officials to violate the law.

    The widespread belief in the existence of “excited delirium” has resulted in a perverse paradox, with both the courts and law enforcement lacking accountability for the conduct of conducting explanations that are medically nonexistent.

    Instead, agencies should request medical support. When officers come across an individual, they should be concerned about their health status. It is not their responsibility to diagnose a person’s condition, which is implicitly expected by the agencies. Law enforcement agencies that provide training to their officers on “excited delirium” are ultimately doing a disservice to them. In conclusion.

    Global Human Rights Legislation

    The United States is also bound by international human rights law, as are other countries such as the United Kingdom, Canada, and Australia, which have spread the term “excited delirium” in multiple contexts where it is used to address the important standards related to the protection from potentially lethal and excessive force. These standards include the necessity for impartial and prompt investigations of deaths in custody, the protection from discrimination in accessing treatment for substance use disorders or mental health, and the protection from discrimination based on disability or race in encounters with law enforcement.

    The Right to Live and Safeguard Against Unnecessary Force by Law Enforcement

    The right to protection, which is entitled to all, is guaranteed by Article 7 of the UDHR and Article 26 of the ICCPR[358]. The United States, having ratified the ICCPR and the UDHR[356], is obligated to uphold Article 6 of the ICCPR and Article 3 of the UDHR, ensuring the right to life.

    Article 10 of the Convention on the Rights of Persons with Disabilities (CRPD) asserts, ‘States Parties reaffirm that every individual possesses the inherent entitlement to life and must take all necessary actions to ensure its effective enjoyment by individuals with disabilities on an equal basis with others.’ Article 5 of the International Convention on the Elimination of All Forms of Racial Discrimination (ICERD), to which the United States is also a participant, guarantees ‘without differentiation based on race, complexion, or national or ethnic origin … The entitlement to personal security and safeguarding by the State against violence or physical harm, whether inflicted by government officials or by any individual group or institution.’ Individuals of diverse racial backgrounds and individuals with disabilities, including mental illness or substance use disorders, hold the entitlement to protection from bias in encounters with law enforcement.

    The “states, Committee Rights Human the of No. Comment General” emphasizes that the use of lethal force for the purposes of law enforcement should only be resorted to when strictly necessary in order to prevent serious injury or protect life, as it is considered an extreme measure.

    Law enforcement agencies should establish guidelines and policies for the utilization of force, as specified by The United Nations Basic Principles on the Use of Force and Firearms by Law Enforcement Officials (1990)[362], within the specified parameters.

  • The utilization of strength should be reduced, focused, proportionate, and aimed towards reducing violence.
  • The careful regulation of “less-lethal” incapacitating weapons is necessary.
  • The use of force by law enforcement agents must be demonstrated in a way that minimizes loss and injury in order to be viewed as appropriate restraint.
  • As per The Basic Principles, law enforcement officials should promptly provide assistance and medical aid to individuals who are injured or affected when the justified use of force cannot be avoided. Furthermore, according to their legislation, “Governments must ensure that the unlawful or excessive use of force and firearms by law enforcement officials is treated as a punishable criminal act.”

    Health Entitlement

    “Article 12 of the International Covenant on Economic, Social and Cultural Rights guarantees the right to the highest possible standard of physical and mental health for everyone. It states that all individuals, regardless of their mental health condition, should be treated with respect and dignity. The United Nations’ principles for the improvement of mental health care and the protection of individuals with mental illness further emphasize the importance of providing appropriate care and protection for those affected.”

    Article 5 of ICERD prohibits any form of racial bias when it comes to accessing medical treatment. Furthermore, Article 25 of the CRPD asserts that individuals with disabilities are entitled to the utmost level of health without any discriminatory practices based on their disability.

    Global Guidelines for Death Investigations and the Right to Redress

    In accordance with the United Nations Principles on the Efficient Prevention and Investigation of Extrajudicial, Arbitrary, and Summary Executions:

    “[369]. In the aforementioned situations, reliable reports of unnatural deaths should be provided by other individuals or relatives who have complaints, where cases include both summary executions and arbitrary extra-legal cases. In all suspected cases, there should be a thorough and impartial investigation that is prompt. Deaths occurring in custody, including situations where executions are carried out, should not be conducted under any circumstances. Such executions, including summary executions and arbitrary extra-legal cases, should be thoroughly and impartially investigated, as suggested by reliable reports from other individuals or relatives with complaints. Governments should pass laws to prohibit all extra-legal, arbitrary, and summary executions.”

    The UN Manual on the Efficient Prevention and Inquiry of Unlawful, Arbitrary and Summary Killings, widely referred to as the Minnesota Protocol and most recently updated in 2016, establishes global benchmarks for the examination of potentially illegal fatalities, including fatalities while under arrest.

    “In order to fulfill their obligations to the deceased’s relatives, forensic doctors or the police (not the State forensic doctors or the police) must clearly understand their obligations to justice and provide an accurate account of the true cause of death, including the surrounding circumstances.”

    [372] The right to judicial remedies, including the effective remedy for a violation of the right to life, is guaranteed by other international declarations and treaties, such as ICERD (Article 6), ICCPR (Article 2), and UDHR (Article 8).

    How the Utilization of “Agitated Delirium” in Law Enforcement Procedures, Death Inquiries, and Judicial Systems Breaches International Legal Standards

    Law enforcement informs individuals experiencing an array of mental health and substance use crises, as well as medical emergencies and disorderly situations, about the disproportionately high number of deaths in custody of Black men and officers who have been absolved of liability in both civil and criminal cases. This is also referred to as “excited delirium,” as described above.

    Some purported signs of “excited delirium” are recognized by trained law enforcement officers to acknowledge the imperviousness to pain and increased strength of individuals of color, particularly Black people, thus perpetuating and exploiting racist tropes and discrimination against them. These same terms of excessive force or lethal employment by law enforcement officers indeed violate international legal protections against racial discrimination, posing a greater risk of harm to people of color and perpetuating racial discrimination in the United States and worldwide.

    Discrimination based on disability or race could potentially violate the right to non-discrimination and the right to access appropriate medical care, which could also mean denying access to necessary medical care for a person experiencing “excited delirium” – a belief held by medical officers that someone experiencing a medical emergency and exhibiting signs of “excited delirium” may have overlapping behaviors. Additionally, people with substance use disorders or mental illnesses may face a disproportionate risk of harm due to violation of protections against disability-based discrimination.

    The term “excited delirium” is often used by coroners, medical examiners, and forensic pathologists to explain deaths in custody, particularly among Black men, which hinders the impartial and prompt investigation of the cause of death and the acceptance and continued use of the term as a cause of death.

    Finally, the violation of the core principle of international law, which is infringing on the fundamental rights of Black men, may have more avenues for an effective remedy. This violation could result in civil liability or criminal prosecution. Additionally, it may foreclose on the explanation of deaths in custody as well as the use of lethal force by law enforcement officers, by allowing the defense of “excited delirium.”

    The allowance of “excited delirium” in courts as a defense for officers’ use of lethal force or as an explanation for deaths in custody may foreclose – and has foreclosed – avenues for criminal prosecution or civil liability, violating a core principle of international law: the right to an effective remedy.


    The use of “excited delirium” should not be considered as a cause of death, as there is rarely written literature that mentions “excited delirium” due to conflicts of interest and the lack of scientific data. Furthermore, there are no established diagnostic standards, agreed-upon underlying pathophysiology or etiology, or a consistent and clear definition for “excited delirium.” Therefore, the diagnosis of “excited delirium” is not medically valid.

    Seemed that the cause of death was delirium, which should be credited to the excited state of mind but at the same time, it appeared to inform of the presence of misogyny and racism.

    In this scenario, if a scientific method was solely or predominantly taking place in a specific environment or context, the investigation of that setting as a contributing or causative element would be necessary for the police to detain the individual. Additionally, deaths that happen during interactions with law enforcement have mainly been attributed to the diagnosis of “excited delirium.”

    The diagnosis of “delirium” has always been advanced by law enforcement-affiliated organizations such as TASER International (Enterprise) and law enforcement agencies, as well as forensic experts and medical physicians, when describing the alarming pattern of pressure from Axon/TASER contributing to the cause of death. These experts, without disclosing the relationships or being paid by defending agencies or TASER/Axon, have raised in the literature the extent to which this diagnosis has been criticized in lawsuits arising out of deaths. This information is based on interviews with legal and medical forensic experts, as well as a review of the literature by PHR’s.

    It is against medical standards for a person who is agitated, mentally ill, or intoxicated to be restrained, beaten, or choked instead of being provided with medical treatment first. It is not appropriate to label this case as “excited delirium” without proper diagnosis, research, or treatment. In order for the diagnostic system to be useful and scientifically valid, criteria and definitions must be created. Additionally, actionable steps towards determining an individual’s treatment needs should be taken into consideration.

    The underlying condition should be medically treated and identified as signs and symptoms. In cases where restraint in a prone position is involved, law enforcement officials should make every effort to avoid causing asphyxia, as it is highly probable that this could be the cause of death.

    The use of “excited delirium” as a means to conceal deaths caused by inappropriate medical or mental health responses, as well as to absolve perpetrators of homicides, and often violent law enforcement actions, has raised concerns for PHR.

    This is a critical step to prevent many preventable deaths before they are acknowledged as what they are. PHR has concluded that it is essential to end the use of “excited delirium” as an official cause of death in cases of deaths in police custody or any other cases. “Excited delirium” should not be used as a medical diagnosis, as it is not a cause of death but rather a descriptive term.


    To ACEP (American College of Emergency Physicians):

  • There is a need for further study on the racial disparities in application, and it is important to note that the usage and origins of “excited delirium” are racist. It should be recognized that “excited delirium” cannot be considered a valid medical diagnosis and the evidence is based on position.
  • In order to eliminate or reduce conflicts of interest in future statements, clear policies should be implemented. To ensure transparency regarding conflicts of interest mentioned in previous statements, all previous white papers supporting the concept of a separate entity known as “excited delirium” should be revoked.
  • To the NAME (National Association of Medical Examiners):

  • There is a need for further study in the racial disparities of application, and it should be noted that the usage and origins of the term “delirium” can be racist. It is important to recognize that “delirium” cannot be a valid medical diagnosis and the statement about it being excited is based on evidence.
  • The investigation into medical examiners’ findings report and custody enforcement law in deaths is conducted publicly, taking into account other factors such as political and structural influences that may affect their independence.
  • To Medical Examiners, Forensic Pathologists, and Coroners:

  • Make sure that “agitated frenzy” is not utilized as either the only or a contributing factor in the certification of death.
  • To Other Associations of Medical and Health Professionals:

  • The study explores how the involvement of law enforcement in the context of health impacts the relationship between healthcare providers and patients, as sought by stakeholders.
  • Establish guidelines for effective communication with families regarding injuries or deaths of loved ones in law enforcement custody.
  • To Municipal and Regional Authorities:

  • General attorneys state instruct that the use of the term “delirium” should be reviewed in all instances when understanding and evaluating correctional and police services.
  • Call the police and first responders to stop disseminating “excited delirium” protocols and collect data on racial disparities, including its use and application of the term.
  • Bolster resources and social services to cater to community needs, such as mental health and harm reduction: Enhance official reactions to individuals facing mental and behavioral health difficulties.
  • Take steps to ensure that medically trained professionals are the primary decision-makers and responders in the management of acute medical emergencies, including substance use disorders and mental health crises.
  • Invest in alternative models of mental and behavioral health crisis response, led by health professionals and/or social workers, rather than law enforcement;.
  • Enhance measures that promote oversight and independence in the investigation of fatalities: Improve the prerequisites and training for physicians conducting autopsies, forensic pathologists, and officers responsible for determining cause of death.
  • Enhance institutional safeguards to guarantee the autonomy of medical examiners, forensic pathologists, and coroners from law enforcement.
  • Implement autonomous supervision mechanisms and require impartial inquiries into fatalities that occur while individuals are in the custody of law enforcement.
  • If a death is indicated on the death certificate as a death in custody, institute rigorous death-in-custody fatality reviews with explicit guidelines;.
  • Prohibit the utilization of neck immobilization and prolonged prone immobilization with additional weight by law enforcement; and.
  • Fund studies on how the involvement of law enforcement in the health context impacts the relationship between patient and health care provider.
  • To the Administration of President Biden:

  • Law enforcement agencies are obligated to annually provide a report to the Attorney General regarding all deaths that occur while in their custody, in accordance with the Death in Custody Reporting Act of 2013 (Pub. L. No. 113-242).
  • The Century 21st Cures Act requires law enforcement to regularly report and collect data related to encounters with individuals suffering from mental illness to the Department of Justice (DOJ) and other relevant parties for enforcement.
  • Implement nationwide guidelines across all federal law enforcement agencies for transparent protocols in death inquiries in federal detention.
  • To promote national standards and unify local and state governments, Congress should work on mechanisms for oversight, investigation, and accreditation that are independent and well-supported, including custody in cases of deaths during investigations.
  • Create a department within the Department of Justice (DOJ) to examine all fatalities that occur while in detention.
  • * We express our gratitude to the Treatment Advocacy Center for its guidance and influence in this matter.

    To the Legislative Assembly:

  • Congress should exercise its authority to provide oversight in order to investigate the use and history of “excited delirium” and the deaths of individuals in police custody, ensuring accountability and justice are pursued across various jurisdictions in the United States.
  • The 2013 Reporting Custody in Death Act requires law enforcement agencies to annually report all deaths in custody to the Attorney General’s office, which the DOJ is responsible for enforcing.
  • The Department of Justice (DOJ) is required to regularly report and collect data on encounters between law enforcement and individuals with mental illness, as mandated by the 21st Century Cures Act. This information is then shared with other relevant parties and the DOJ ensures its enforcement.
  • Establish systems for supervision and monitoring of any forceful strategies employed to subdue or manage individuals in police detention.
  • Legislation is being pursued that aims to establish national standards towards which police violence investigations and death documentation procedures for death certificates must adhere, ensuring quality assurance.
  • Prohibiting the utilization of neck restriction and heavy or prolonged lying face down restraint by law enforcement;.
  • Allocate resources for: An essential nationwide database overseeing the utilization of coercion by law enforcement, encompassing data regarding psychological well-being conditions, ethnic background, and race.
  • Strengthened non-law enforcement emergency mental health services and social services response programs at both the state and local levels; as well as the development of new or enhanced programs.
  • Research on the impact of law enforcement’s participation in the healthcare field on the connection between patients and healthcare providers.
  • *We express our gratitude to the Treatment Advocacy Center for their exemplary guidance on this matter.

    Addressed to the Centers for Disease Control and Prevention in the United States:

  • Incorporate an obligatory checkbox on the typical death certificate in the United States to enable doctors to record deaths that transpire while under supervision;* and.
  • This review undertakes a analysis of the demographics of the people whom this term “excited delirium” was applied to, as well as the common situations in which it was invoked. It also examines other disparities in health, including racial disparities, as a matter of reviewing deaths in custody.
  • * This recommendation was suggested to PHR by Dr. Roger Mitchell, chair of the Department of Pathology, Howard University College of Medicine.

    To United Nations Human Rights Mechanisms, including the Independent Expert Mechanism on Structural Racism in Law Enforcement:

  • The use of the term “delirium” in the report and study serves as an explanation for the implications of human rights and deaths in custody, tracing the geographic scope of its use worldwide. It also functions as an oversight and reporting mechanism for both international and state levels.
  • Acknowledgments

    We would like to thank Cassandra Quinto-Collins and Bella Quinto-Collins, Joe Prude, Robert Collins, and all the courageous families and survivors who have lost their loved ones to police violence for sharing their stories with us. Without them, this report would not have been possible. Our gratitude goes to Physicians for Human Rights (PHR).

    The conclusions and findings in the medical report were not influenced by the thematic and historical analysis, but were based solely on the analysis conducted by the team members, who had expertise in both legal and medical backgrounds. Olivia O’Leary, Joshua Martins-Caulfield, and Esther Choo, who were interns at PHR, contributed to the writing of this report. Gerson Smoger, a member of the PHR Advisory Council and a civil rights lawyer, also contributed to the writing of this report. Additionally, Julia Sherwin, a JD from Harvard Law School, Altaf Saadi, an instructor in neurology at Harvard Medical School and a neurologist at Massachusetts General Hospital, Joanna Mitchell-Naples, a researcher at PHR, Michele Heisler, a professor of public health and internal medicine, and Brianna da Silva Bhatia, an internal medicine physician, all contributed to the writing of this report.

    Brianna da Silva Bhatia, Michele Heisler, Joanna Naples-Mitchell, and Julia Sherwin carried out interviews for the report. Susannah Sirkin, MEd, former PHR director of policy and senior advisor, Rohini Haar, MP, MPH, PHR medical advisor, Joseph Leone, former PHR research and investigations fellow, Phelim Kine, former PHR director of research and investigations, PHR Advisory Council Members Jennifer Leaning, MD, SMH and Nizam Peerwani, MD, and Lindsey Thomas, MD, contributed to the research design. Homer Venters, MD, former PHR director of programs, came up with the idea for a report on this topic. Esther Choo, Madelaine Graber, Riyana Lalani, Joseph Leone, and Olivia O’Leary conducted background research. Brian Hawkinson, JD, and Paulina Piasecki, JD, provided assistance with legal research.

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    Hannah Dunphy, digital communications manager, was responsible for preparing the digital presentation. Claudia Rader, senior communications manager, reviewed, edited, and prepared the report for publication with the help of Samantha Peck, executive assistant.