The term was referenced in the deaths of Sheldon Haleck and Richard Gregory.

UPDATED: The Honolulu Police Department will be “reviewing its policies following the association’s announcement,” spokeswoman Michelle Yu said Monday.

A prominent medical organization recently announced it no longer endorsed a contentious cause of death often used to categorize how people die when being restrained by police.

The term “excited delirium” gained traction in the mid-1980s and was promoted in training literature by companies with links to law enforcement and through a small pool of prolific expert medical witnesses.

But the National Association of Medical Examiners announced this month that it would no longer endorse use of the terms “excited delirium” or “excited delirium syndrome.”

“Instead, NAME endorses that the underlying cause, natural or unnatural (to include trauma), for the delirious state be determined (if possible) and used for death certification,” the association said in a statement.

Sheldon Haleck died after being tased by Honolulu police. “Excited Delirium” was cited as a factor in the police response and his behavior during the incident. (Screenshot/HPD)

The term is often applied to people who show signs of distress or aggression from drugs or mental illness, but a 2018 review of the scientific literature found that reports of excited delirium are more likely to surface in cases involving young Black men who are overweight, using drugs, or are psychiatric patients.

Cases where excited delirium is referenced were most likely to be fatal and occur where police had used aggressive restraint methods including manhandling, handcuffs and hobble ties, according to a major 2020 study.

In May 2020, as former Minneapolis police officer Derek Chauvin knelt on George Floyd’s neck until he died, another officer, Thomas Lane, said, “I am worried about excited delirium or whatever.” The deaths of Floyd and others increased scrutiny on the use of the term and its influence on policing techniques and post-mortem conclusions on causes of death.

The death of George Floyd in 2020 increased scrutiny on the use of the term “Excited Delirium” to describe the physical reactions of suspects who are being restrained. (Court TV/AP/2020)

NAME was one of two medical associations that continued to support the term, until reversing its position after the advocacy group Physicians for Human Rights released an investigation into the term that examined its racial origins in March 2022.

“For years, NAME has offered a veneer of medical legitimacy to this pseudoscientific and dangerous term, allowing responsibility for deaths to be shifted away from law enforcement officers,” the report’s co-author Joanna Naples-Mitchell, a research adviser for PHR, said in a press release. “Much damage has been done, but as of today clinicians, litigators, and police can no longer look to NAME for endorsement of ‘excited delirium.'”

The American College of Emergency Physicians still endorses the term “excited delirium,” according to Physicians for Human Rights. The association did not respond to a request for comment.

Role In Prominent Hawaii Cases

Excited delirium has surfaced as an alleged cause of death in a number of high-profile cases in Hawaii.

In 2014, taxpayers covered the $1.4 million settlement to the family of 37-year-old Aaron Torres, who died after Honolulu police officers restrained him in 2012. The cause of death was “mechanical asphyxia during police restraint due to or as a consequence of a cocaine induced excited delirium,” the medical examiner determined.

Aaron Torres was killed after being restrained by Honolulu police on Feb. 20, 2012. “Excited Delirium” was cited as a cause of death. (Screenshot/Provided)

“At this point, nobody’s using the term, and I think I will keep it that way. There is no good definition,” said Masahiko “Mike” Kobayashi, Honolulu’s medical examiner.

Excited delirium was listed as a cause of death eight times between 2004 to 2012, Kobayashi said after searching his case files. But when Christopher Happy took over as medical examiner in 2013, he instructed others in the office not to use the term because he didn’t like it, Kobayashi said.

Happy, who resigned in 2019, did not respond to a request for comment.

“So we haven’t used it in like 10 years,” Kobayashi said. “But we’ve had similar cases, where people died during the restraint, but we didn’t use this particular term in the cause of death.”

While the term isn’t often listed as a cause of death, the medical examiners may still use the term in an autopsy report, Kobayashi said.

“I usually don’t determine there was excited delirium,” he said. “It’s very complicated. Usually there are many, many factors in the death.”

Those factors include methamphetamines, large body size, heart problems, and increased heart rate from a scuffle with police, Kobayashi said. “This combination can cause all the disturbance within the body and that can cause death.”

Lawsuits have linked the term and myriad effects to police encounters where Tasers are deployed.

Sheldon Haleck, a former Hawaii Air National Guardsman, died in 2015 after Honolulu police officers used their Tasers on him, in line with HPD policy.

Happy, then medical examiner, determined the cause of death was multiple metabolic and cardiac complications due to “physical altercation with police in (an) individual acutely intoxicated with methamphetamine,” he wrote in the autopsy report.

“Acute delirium, agitation, and psychosis following drug use, especially stimulant drug use, has been described in the medical and forensic pathology literature as ‘Excited Delirium Syndrome,'” Happy wrote. “Mr. Haleck displayed many of the signs and symptoms described in this syndrome. However, there are currently no well established diagnostic criteria for this syndrome.”

Friends and family gather for Sheldon Paul Haleck's  memorial 1 year service at Maunalua Bay. 19 march 2016.
A civil rights lawsuit against three HPD officers involved in the death of Sheldon Haleck was unsuccessful. (Cory Lum/Civil Beat/2016)

Haleck’s uncle filed a civil rights lawsuit in 2015 against the three police officers involved. When it went to trial, the city’s attorneys argued that the Taser deployment didn’t kill Haleck but that excited delirium was the cause.

The city hired expert witnesses who had ties to the company that makes Tasers, Axon Enterprises, Inc. Two of the witnesses, Stacey Hail, an emergency physician from Texas, and Mark Kroll, a director for Axon, had co-written a study that downplayed the role that Conducted Energy Weapons had on increased levels of serotonin in people who had been tased.

Another witness was John G. Peters, a certified Taser instructor and president of the Institute for the Prevention of In-Custody Deaths, who participated in scientific studies on excited delirium.

A jury determined that the officers who engaged Haleck did not use excessive force when they tried to arrest him.

Similar issues were adjudicated following the death in 2002 of Richard Gregory on Lahaina as he was being subdued by Maui County police officers.

In that instance the 9th U.S. Circuit Court of Appeals also found police had not used excessive force, while his estate argued the officers should have recognized symptoms of excited delirium and modified their restraint accordingly because of the high risk of fatality. The case is now a frequent footnote in legal studies of excited delirium and use of force.

The Honolulu Police Department’s policy on Tasers currently still references the term excited delirium in a way that points to its indeterminate meaning.

“Individuals suspected of being under the influence of drugs/alcohol or exhibiting symptoms of excited delirium (e.g. nudity, profuse sweating, and irrational behavior) may be more susceptible to collateral problems and should be closely monitored” after being tased and until they receive medical attention, the policy states.

Officers also have latitude as to whether they should deliver the initial shock.

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