Court-appointed Guardians Research Articles

Transcultural Psychiatry in Medical Ethics: Assessing Decision-Making Capacity within the Lens of an East African Refugee.

AbstractA 29-year-old female East African refugee with no formal psychiatric history and a medical history significant for HIV was admitted for failure to thrive and concern for bizarre behavior in the context of abandonment by her husband and separation from her child. After psychiatric evaluation, it was determined that she did not have the capacity to care for herself independently; adult protective services then pursued and was awarded guardianship. While admitted, the patient repeatedly refused medical treatment, had a feeding tube placed for forced nutrition and medications (though she did at one point remove this tube herself), and received two electroconvulsive therapy (ECT) treatments. Soon thereafter, the patient's court-appointed guardian met with the primary medical, psychiatric, and ethics teams to discuss goals of care in the setting of complex social and cultural needs. It was collectively determined that the patient's choices to refuse care (including nutrition, lab work, medications, and ECT) and some repeated behaviors (e.g., denial of divorce, denial of HIV, denial of need for care) could be considered culturally appropriate in the context of the acute stressors leading up to hospitalizations. All teams concluded, therefore, that the patient had the capacity to refuse these interventions and that further forced intervention would pose a greater chance of exacerbating her already-significant trauma history than improving her outcomes. Ultimately, the patient was able to be discharged into the care of her guardian, who would assist her in receiving support from members of her community who share her language and culture.

The Effect of Delay Following the Clinical Decision to Perform Tracheostomy in the Critical Care Setting.

Tracheostomy in patients who are critically ill is generally performed due to prolonged mechanical ventilation and expected extubation failure. However, tracheostomy criteria and ideal timing are poorly defined, including equivocal data from randomized controlled trials and median intubation to tracheostomy times that range from 7-21 d. However, a consistent finding is that only ∼50% of late tracheostomy groups actually undergo tracheostomy, with non-performance due to recovery or clinical deterioration. Unlike in many jurisdictions, elective surgical procedures in our institution require a court-appointed guardian, which necessitates an approximately 1-week delay between the decision to perform tracheostomy and surgery. This offers a unique opportunity to observe patients with potential tracheostomy during a delay between the decision and the performance. ICU patients who were ventilated were identified for inclusion retrospectively by an application for guardianship relating to tracheostomy, the intention-to-treat point. The main outcomes of tracheostomy, extubation, or death/palliative care after inclusion were noted. Demographics, outcomes, and event timing were compared for the 3 outcome groups. Tracheostomy-related guardianship requests were made for 388 subjects. Of these, 195 (50%) underwent tracheostomy, whereas 127 (33%) were extubated and 66 (17%) either died before tracheostomy (46 [12%]) or were transitioned to palliative care (20 [5%]). The median time (interquartile range) from guardianship request until a defining event was the following: 6.2 (4.0-11) d for tracheostomy, 5.0 (2.9-8.2) d for extubation (P < .001 as compared to tracheostomy group), and 6.5 (2.5-11) d for death/palliative care (P = .55 as compared to tracheostomy). Neurological admissions were more common in the tracheostomy group and less common in the palliative group. Other admission demographics and hospitalization characteristics were similar. Hospital mortality was higher for subjects undergoing tracheostomy (58/195 [30%]) versus extubation (24/127 [19%]) (P = .03). Delay in performing tracheostomy due to legal requirements was associated with a 50% decrease in the need for tracheostomy. This suggests that decision-making with regard to ideal tracheostomy timing could be improved, saving unnecessary procedures.

Preventing Abuses in Guardianship Cases.

Guardianships allow court-appointed guardians to make decisions on behalf of persons who are incapable of caring for themselves. With their authority frequently extending over both the personal and the financial affairs of a ward, guardians sometimes abuse their extensive powers. Misuse of funds, excessive fees, and neglect of the ward's needs all have been seen in guardianship cases. As awareness of this problem has grown, innovative approaches have been developed to prevent and detect abuses, including mandatory certification, centralized audits, and visits to persons under guardianship to assess their status. Funding such efforts, however, remains a challenge.

Parent-Child Contacts in the Presence of Legal Court-Appointed Guardian. Practice in View of the Need for Legislative Change

Abstract Contact with the child has for years been the subject of deliberations and discussions of entities interested in the welfare of the child, often caught up in the conflict between the parents. They concern, among others, the role of professional guardians/probation officers, whose presence during parent-child contact, according to the law, constitutes one of the forms of court restrictions on this form of maintenance of the parent-child relationship. The aim of the text is an attempt to identify the technical problems associated with the implementation of the court decisions in this matter, and thus to indicate the gross disproportion between the current shape of the regulations on the participation of a guardian in parent-child contact and the needs of practice. Thus, the aim of the study is to engage the community of guardians in the ongoing work on legislative changes and the potential effects of the proposed legislation, including substantive and implementing provisions of family law aimed at the guaranteed right to contact with the child.

Guardianship Before and Following Hospitalization.

When ethics committees are consulted about patients who have or need court-appointed guardians, they lack empirical evidence about several common issues, including the relationship between guardianship and prolonged, potentially medically unnecessary hospitalizations for patients. To provide information about this issue, we conducted quantitative and qualitative analyses using a retrospective cohort from Veterans Healthcare Administration. To examine the relationship between guardianship appointment and hospital length of stay, we first compared 116 persons hospitalized prior to guardianship appointment to a comparison group (n = 348) 3:1 matched for age, diagnosis, date of admission, and comorbidity. We then compared 91 persons hospitalized in the year following guardianship appointment to a second matched comparison group (n = 273). Mean length of stay was 30.75days (SD = 46.70) amongst those admitted prior to guardianship, which was higher than the comparison group (M = 7.74, SD = 9.71, F = 20.75, p < .001). Length of stay was lower following guardianship appointment (11.65, SD = 12.02, t = 15.16, p < .001); while higher than the comparison group (M = 7.60, SD = 8.46), differences were not associated with guardianship status. In a separate analysis involving 35 individuals who were hospitalized both prior to and following guardianship, length of stay was longer in the year prior (M = 23.00, SD = 37.55) versus after guardianship (M = 10.37, SD = 10.89, F = 4.35, p = .045). In qualitative analyses, four themes associated with lengths of stay exceeding 45days prior to guardianship appointment were: administrative issues, family conflict, neuropsychiatric comorbidity, and medical complications. Our results suggest that persons who are admitted to hospitals, and subsequently require a guardian, experience extended lengths of stay for multiple complex reasons. Once a guardian has been appointed, however, differences in hospital lengths of stay between patients with and without guardians are reduced.

Fluctuating Decision-Making in People with Mental Illness

Fluctuating Decision-Making in People with Mental Illness

Determinants of the work of a court-appointed guardian in Poland

The profession of a court-appointed guardian belongs to the so-called social professions. This means that the person performing such a profession has direct and constant contact with people. In Poland, a very important legal act regulating the work of a court-appointed guardian is the Act of 27 July 2001 on court-appointed guardians which emphasizes that the legal supervision is a professional social service. As a public officer cooperates not only with the ward and their immediate environment, but also with institutions and institutions dealing with care, education, rehabilitation, treatment, counselling and social assistance. The actions taken by the court-appointed guardians are of educational and social rehabilitation, diagnostic, preventive, and supervision nature. The purpose of this article is to analyse the conditions of the work of a court-appointed guardian.

Tymczasowość rodzinnych form pieczy zastępczej w świetle wyników badań empirycznych

If a family is not able to provide the necessary care for the child, he or she is placed outside the family. The purpose of such an action, however, should be the child’s return to his or her family environment as foster care is auxiliary to the natural and primary form of custody provided by biological parents. The principle of the temporary nature of foster care was formulated in the provisions of the Act of 9 June 2011 on Family Support and Foster Care. Pursuant to this act, upon the expiry of 18 months from the day when the child was placed in foster care, the family court at the request of the entity organising foster care should issue a decision concerning the child in order to determine the child’s legal situation. This article aims to present the results of the studies carried out between March and September 2020 as part of the research project ‘The temporary nature of family foster care’. It sought to verify compliance with the principle of the temporary nature of family foster care. The project involved interviews with foster parents, foster children and experts (family judges, social workers from Social Welfare Centres (OPS) and Poviat Family Support Centres (PCPR), employees of adoption centres and foster care centres as well as professional court-appointed guardians). The article is based on the conclusions drawn from 34 interviews with foster parents representing different forms of family foster care (kinship foster families; professional, non-professional, and specialized foster families; emergency family shelters, and family-run children’s homes).

Self-Neglect: One Pathway to Surrogate Decision-Making

Self-neglect, the most frequently reported allegation to Adult Protective Services (APS), involves profoundly harmful behaviors often due to functional or cognitive limitations, health problems, and insufficient resources that result in older adults insufficiently meeting their basic needs. Outcomes include high risk of illness, hospitalization and readmission, hospice and nursing home use, early mortality, and placement under surrogate decision-making authority of either well-intended or opportunistic others. APS staff are charged with assessing self-neglect and intervening to reduce client danger. A nationwide APS survey revealed program policies, procedures, resources, and needs affecting the client welfare. For example, 92% of APS programs have provisions for seeking guardianship for self-neglecting individuals, in 25% of programs staff serve as court-appointed guardians, and a wide variety of tools are used within APS programs to assess clients’ mental capacity. Key study findings, implications, and recommendations will be presented.

Paradox of Becoming Wealthy in J. Blakeson's I Care a Lot

The American dream is a national ethos that originated in the United States of America and is widely known and believed by people all over the world. In order to create their American dream, particularly the dream of becoming wealthy, traditional American values are required. In the midst of fulfilling one American dream, a person may unknowingly create a paradox by doing things that are believed to be true but are ironically incorrect. The paradox of becoming wealthy can be found in a person's endeavor by following traditional American principles or inside its actual profession by engaging in a criminal action, sometimes known as a crime. The paradox appeared in the movie I Care a Lot by J. Blakeson which tells the story of Marla Grayson, a court-appointed guardian for the elderly who uses her wards as a weapon to achieve her American goal of being wealthy, and Dr. Karen Amos, a physician who sells personal information about her patients in order to get rich. Both committed a crime and transgressed conventional American principles of material prosperity and hard effort.

ADVOCATING FOR OLDER ADULTS: WHEN GUARDIANSHIP IS NOT THE ANSWER: Session 403

When an adult is thought to be making poor decisions or is unable to care for him or herself, many people assume that a guardianship is necessary to secure that person's well being. An older adult may require a guardian because of a new inability to care for themselves in the contest of a neurocognitive disorder, or after a lifetime of chronic mental illness, and self-neglect. The appointment of a guardian by the court can be lifesaving, provide much needed financial protection from exploitation, and guarantee stable housing and access to health care. However, a guardianship may also leave older adults vulnerable to abuse and financial exploitation. In many cases, the needs of older adults are layered and complex, and guardianship is not necessarily the best remedy, especially when the court-appointed guardians may be responsible for hundreds of clients.

Autopercepcja bezpośrednich oddziaływań wychowawczych społecznych kuratorów sądowych

W artykule dokonano oceny sposobów wywierania wpływu wychowawczego społecznych kuratorów sądowych. Wprowadzenie teoretyczne zawiera krótką analizę mieszanego modelu kurateli sądowej dla dorosłych i uwarunkowań oddziaływań resocjalizacyjnych w pracy z osobami, u których przestępczość łączy się z czynnikami ryzyka i zaburzeniami związanymi z problemem alkoholowym. W części empirycznej zaprezentowano autopercepcję sposobów oddziaływań wychowawczych społecznych kuratorów sądowych. Przedstawione badania są unikalne na tle dotychczasowych, jednostronnych analiz pracy kuratorów opartych głównie na ocenie zapisów kart czynności wytwarzanych przez samych kuratorów.

“They Can't Do That?” The Role of Court-Appointed Guardians in End-of-Life Decision-Making (TH311)

“They Can't Do That?” The Role of Court-Appointed Guardians in End-of-Life Decision-Making (TH311)

Collaborative Care for a Woman With Traumatic Brain Injury During Pregnancy

In this case study, we focus on a woman who experienced a traumatic brain injury (TBI) during pregnancy. Special considerations regarding care of the pregnant woman in a rehabilitation setting, development of vancomycin-resistant enterococci colonization in open cranial flap, current immunization recommendations during pregnancy, methods for screening for gestational diabetes mellitus in an aphasic woman, and the importance of a team approach in collaborative care are presented. The woman had an open cranial flap (approximately 10 cm in diameter) with vancomycin-resistant enterococci colonization. She had a history of marijuana and methamphetamine use and pre-existing epilepsy. Her mother, who was her primary support person, was not granted guardianship during the woman’s hospitalization; instead, there was a court-appointed guardian. The woman experienced malnutrition following TBI. She was immobile, required a two-person transfer, and was aphasic and combative. She experienced silent aspiration with thin liquids and was hypokalemic and hypoalbuminemic. The borderline low estimated fetal weight and chronic opioid use for pain following TBI raised concern regarding neonatal abstinence syndrome of the newborn. Implications for nursing practice include reviewing current immunization guidelines during pregnancy (influenza, Tdap, and pneumonia), identifying alternate methods for gestational diabetes mellitus screening in an aphasic patient, considering the timing of birth, and being aware of the potential for neonatal abstinence syndrome. We also discuss the value of interdisciplinary planning before, during, and after hospitalization.

P140: Emergency department decision-making for incapacitated and unrepresented patients: a comprehensive review of the literature

Introduction: Incapacitated patients who lack substitute decision-makers (SDM) are commonly encountered in the emergency department (ED). The number of these patients will rise dramatically as the Baby Boomers age. We can expect an influx of elderly patients who lack decisional capacity due to dementia and other illnesses, and who present without family. It is estimated that 3 to 4 percent of U.S. nursing home residents have no SDM or advance directives. Medical decision-making for this cohort poses an ethical challenge, particularly in the ED setting. Methods: A comprehensive review of the literature was conducted surrounding decision-making for incapacitated and unrepresented patients in the hospital setting. Articles were identified using MEDLINE (1946-October 2015) and Embase (1974-October 2015). The reference lists of relevant articles were hand searched. Articles describing decision-making processes that have been proposed, tested or applied in practice were chosen for full review. The aim of this review was to outline recognized medical decision-making processes for incapacitated and unrepresented patients, and to identify areas for future research. Results: The search yielded 20 articles addressing decision-making for incapacitated and unrepresented patients in the hospital setting. All of these articles focus on the intensive care unit and other hospital wards; no literature on the ED setting was found. Five types of formal consulting bodies exist to assist physicians in applying the best interest standard for this patient cohort: internal hospital ethics committees, external ethics committees, public guardians, court-appointed guardians, or judges. The majority of decisions for these patients, however, are made informally by a single physician or by a healthcare team, although it is well recognized that this approach lacks appropriate safeguards. There is no consensus surrounding the optimal approach to decision-making in these cases, and as such there is significant inconsistency in how medical decisions are made for these patients. Conclusion: There are several articles describing decision-making processes for incapacitated and unrepresented patients, none of which focus on the ED. These processes are not practical for use in the ED. Further inquiry is needed into the most ethical and respectful method of decision-making for this patient cohort in the ED.

When Client Rights and Safety Concerns Collide: Ethical Considerations With Severely Mentally Ill or Intellectually or Developmentally Disabled Clients

Many adults that are severely mentally ill or intellectually or developmentally disabled have state- or court-appointed guardians because they are unable to make sound and safe decisions regarding their lives because of impaired functionality or cognitive abilities. This article will use vignettes to illustrate the types of ethical and moral conflicts that can potentially arise between client and guardian and to discuss existing disconnects between basic human rights and issues regarding safety when clients are in service with a supported living agency. Ethical dilemmas abound when an individual makes assumptions and decisions regarding the lives of another, so where that line is or should be drawn can be a difficult one to conceptualize. This article will illustrate how acting as a client-centered agency may often go against the perceived “good” of the client, and who ultimately has the right to determine quality-of-life issues within the theoretical constructs of client-centered support.

The ‘Unbefriended’ Challenge PA/LTC

The ‘Unbefriended’ Challenge PA/LTC

Succession of Property, Sales of Meação, and the Economic Empowerment of Widows of African Descent in Colonial Minas Gerais, Brazil

Although Portuguese laws protected women’s right to property, the process of succession that followed a husband’s death in colonial Minas Gerais often threatened women’s economic well-being. Widows of African descent, moreover, were regularly denied custody of their children, having to defer to court-appointed guardians in matters regarding their property and education. In this context, some couples contracted the sale of the dying spouse’s meação to the surviving spouse. This understudied strategy of transmission of property empowered widows of African descent to act as heads of household and guardians to their children in ways that were not guaranteed by law.

Hardships of End-of-Life Care With Court-Appointed Guardians

In the United States, the court-appointed guardians do not have the ability to make decisions regarding end-of-life (EOL) care for their clients. Additionally, the process of initiating EOL care measures can be slow and cumbersome, despite an existing process of getting approval for such care. This process has the potential to prolong suffering and delay imperative decisions. This article reviews the hardships that patients, court-appointed guardians, and health care staff endure while moving through the oppressive process of obtaining EOL care orders through the court. This article also proposes ways of tuning up the laws, regulations, and communications to make it easier and faster to obtain orders regarding EOL care to preserve the dignity of our patients and loved ones. "A guardianship is a legal relationship created when a person or institution named in a will or assigned by the court to take care of minor children or incompetent adults."

Standards for Health Care Decision-Making: Legal and Practical Considerations

In contemporary guardianship systems, it is likely that most court-appointed guardians will eventually be called upon either to make or to assist the ward to make health care decisions of many sorts. These decisions may involve matters as simple as scheduling physician or dental appointments for the ward, helping her to complete medical history forms, and authorizing nonemergency treatment for minor illnesses or injuries. They may also involve such critical decisions as whether to permit risky surgical procedures, to switch from curative care that is unlikely to cure in favor of palliative care and aggressive pain management, or to direct health care providers to terminate ongoing, life-sustaining treatments including artificial respiration, nutrition, or hydration. Often, these health care decisions must be made in circumstances where time is of the essence or stress levels are high due to the seriousness of the ward’s medical situation and the possible deleterious, irreversible consequences of a “wrong” decision. Persons other than the guardian—a family member or care giver, for example—may wish to, or feel entitled to, have a role in the decision-making process. Persons interested in the ward’s welfare, but who do not have legal authority to make decisions in her behalf, may seek to involve themselves in health care decision-making, although not always in ways that would best serve the preferences, interests, and needs of the person under guardianship.