This is The Marshall Project’s Closing Argument newsletter, a weekly deep dive into a key criminal justice issue. Want this delivered to your inbox? Subscribe to future newsletters.
Last week, Minnesota became the third state to pass legislation restricting the concept of “excited delirium,” a term frequently used by authorities to describe the condition of people who die in police custody.
Here’s where you’re probably expecting me to explain what excited delirium is — but that’s more difficult than it sounds because there has never been consensus on it, according to a 2022 review by the advocacy group Physicians for Human Rights. First responders across the country have used the term for decades as a catchall field diagnosis for people in extreme agitation related to drug use, psychiatric illness or cognitive disorders. Many police have been trained to believe that excited delirium causes “superhuman strength,” imperviousness to pain and extreme aggression. Medical examiners have sometimes used the term to describe the theory that someone got so agitated — generally during police restraint — that their heart just stopped.
That lack of clarity is one of the major reasons that professional medical associations have increasingly denounced the term as, at best, useless, and at worst, racist pseudoscience and a tool intended to hide or excuse police violence. This past October, the American College of Emergency Physicians — the last major association that still recognized excited delirium — withdrew a 2009 paper that was supportive of the concept. That same month, California became the first state to legislate its use, banning coroners and medical examiners from using the term on death certificates and police from using it in reports.
Colorado followed in April, going a step further by banning the term in police training materials. New York and Hawaii also have legislation in the works, according to Kaiser Family Foundation Health News. Supporters of these bills have argued that excited delirium is often used to excuse deaths that may have been caused — at least in part — by police use of force, specifically restraint.
Delirium itself is an uncontroversial medical concept, and “hyperactive delirium” is recognized in psychiatric and emergency medicine literature — but as a group of symptoms caused by an underlying health issue, not as a cause of death. “You can’t say that someone dies from any form of delirium,” Dr. Michele Heisler, medical director of Physicians for Human Rights, told CNN in 2022, comparing it to claiming someone died of “chest pain” or “shortness of breath.” Medical professionals do not define super strength, aggression and uncommon pain tolerance as part of hyperactive delirium.
According to an analysis published this week by the Center for Policing Equity, excited or agitated delirium is mentioned in about 17% of official “cause-of-death statements” after someone dies following police use of force, when that force is not a gun. The think tank, founded in 2008, works on issues of racial disparities in policing.
Justin Feldman, one of the researchers who conducted the study, told me that holding police accountable for deaths in custody goes beyond the problems with the concept of excited delirium. He’s skeptical that efforts to ban the term will have a meaningful impact. “It is very easy to come up with another explanation” that also excludes police use of force as a cause of death, Feldman said. That could mean using a synonym for excited delirium or citing other non-police causes of death, like drug use.
From the law enforcement perspective, Chuck Wexler, the executive director of the Police Executive Research Forum, agrees on the limits of word choice. “Police will continue to encounter these people, whether we call their crises ‘excited delirium,’ ‘hyperactive delirium,’ or simply describe their behavior,” Wexler wrote in a March post on the organization’s website. He argued that what matters is how police respond to people experiencing the kinds of behavioral health crises that are often lumped into the term.
For years, statewide police training materials in Florida advised officers to taser and restrain people with excited delirium, according to a recent investigation by Tampa-area TV station WTSP. Then, in 2023, without abandoning the term, the state changed excited delirium training to emphasize patient safety with tactics like “verbal calming” and “rapid de-escalation,” and actions like turning off lights and sirens. According to the station’s reporting, however, the updated guidance has been slow to trickle into local police policy and training materials.
Excited delirium is also frequently cited as a rationale for forced medication by emergency medical workers, specifically the injection of the anesthetic, ketamine. In the most well-known instance, EMTs in Colorado injected 23-year-old Elijah McClain with the drug in 2019 after police restrained him while investigating a “suspicious person” call. Medical first responders claimed McClain showed signs of excited delirium based on the look in his eyes and exhibiting unusual strength. In a rare occurrence, two paramedics and one police officer involved were convicted of crimes in McClain’s death.
An April investigation by The Associated Press found that nearly 100 people over a 10-year span died after being injected with sedatives like ketamine as they were restrained by police — while also noting that it’s “impossible to determine the role sedatives may have played” in those deaths.
