DECISION MAKING FOR THOSE WITHOUT CAPACITY AND SURROGATES: LEGAL, FINANCIAL, AND HEALTHCARE PERSPECTIVES

Adults with diminished decision making capacity, no advance directive, and who lack family, friends, or a legally authorized surrogate to serve as an advocate, decision supporter, and decision maker - so called “unbefriended” - are among the most vulnerable in healthcare. Often - once all efforts to identify family/friends and maximize capacity have been tried, such individuals have a surrogate appointment by a court. In some states this appointment falls under a “public guardianship” system. In other states a more haphazard approach is used. Guardianship in such situations may be the only option - and yet itself is fraught with challenges such as finding adults to serve as guardians, appropriately compensating good guardians, and monitoring for abuse. In this symposium we tackle this issue from different disciplinary perspectives, drawing from state and national data. In the first presentation Dr. Connors will present a policy perspective, discussing public guardianship law and describing recent legislative efforts in Massachusetts. Next, Dr. Moye will present findings from a state wide survey of clinicians, guardians, and legal counsel in Massachusetts, noting challenges encountered in such situations such as prolonged hospital stays (65.8%), palliative care delay (51.9%), continuation of non-beneficial care (39%). Provision of guardianship may reduce these consequences, and have associated financial costs and cost-offset which will be discussed by Dr. Levine in the third presentation. In the final presentation, Ms. Catlin will present the results of a nationwide survey of American Geriatric Society members regarding its recent policy on “unbefriended” adults, and potential solutions.