Guardianship: The Implications of Resident Physician Perceptions of Caring for Incapacitated Older Adults Without Advocates

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Abstract

As the incidence of dementia rises, increased utilization of surrogate decision-makers, including legal guardians, is anticipated. This manuscript presents an analysis of resident physicians’ experiences and perceptions regarding requirements, roles, and responsibilities of caring for older adults in need of, or already under, legal guardianship. This is a cross-sectional study, conducted at a tertiary academic medical center. A survey was sent, via Qualtrics, to all emergency medicine, family medicine, internal medicine, general surgery, and medicine-pediatric resident physicians. Eighty-eight out of three hundred thirty-three (26.4%) eligible residents physicians completed the survey. Most (98.9%) reported caring for patients under guardianship, yet many resident physicians reported significant uncertainty regarding the roles and responsibilities of guardianship, including its potential benefits and limitations. They also displayed misconceptions and overconfidence about guardians’ abilities to facilitate disposition, ensure financial security, and assign code status, among other matters. Our study highlights the importance of structured and directed education on the topic of guardianship for medical trainees.

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Most cited references 10

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Estimating the Prevalence of Dementia and Mild Cognitive Impairment in the US : The 2016 Health and Retirement Study Harmonized Cognitive Assessment Protocol Project

Jennifer Manly, Richard N Jones, Kenneth M Langa … (2022)

Importance Nationally representative data are critical for understanding the causes, costs, and outcomes associated with dementia and mild cognitive impairment (MCI) in the US and can inform policies aimed at reducing the impact of these conditions on patients, families, and public programs. The nationally representative Health and Retirement Study (HRS) is an essential resource for such data, but the HRS substudy providing dementia diagnostic information was fielded more than 20 years ago and more recent data are needed. Objective The Harmonized Cognitive Assessment Protocol (HCAP) was developed to update national estimates of the prevalence of MCI and dementia in the US and examine differences by age, race, ethnicity, and sex. Design, Setting, and Participants HRS is an ongoing longitudinal nationally representative study of people 51 years and older with staggered entry dates from 1992 to 2022 and follow-up ranging from 4 to 30 years. HCAP is a cross-sectional random sample of individuals in HRS who were 65 years or older in 2016. Of 9972 age-eligible HRS participants, 4425 were randomly selected for HCAP, and 3496 completed a comprehensive neuropsychological test battery and informant interview, none of whom were excluded. Dementia and MCI were classified using an algorithm based on standard diagnostic criteria and comparing test performance to a robust normative sample. Exposures Groups were stratified by age, sex, education, race, and ethnicity. Main Outcomes and Measures National prevalence estimates using population weights. Results The mean (SD) age of the study population sample (N = 3496) was 76.4 (7.6) years, and 2095 participants (60%) were female. There were 551 participants who self-identified as Black and not Hispanic (16%), 382 who self-identified as Hispanic regardless of race (16%), 2483 who self-identified as White and not Hispanic (71%), and 80 who self-identified as another race (2%), including American Indian or Alaska Native, Asian, Native Hawaiian or Pacific Islander, or another self-described race. A total of 393 individuals (10%; 95% CI, 9-11) were classified as having dementia and 804 (22%; 95% CI, 20-24) as having MCI. Every 5-year increase in age was associated with higher risk of dementia (weighted odds ratio [OR], 1.95 per 5-year age difference; 95%, CI, 1.77-2.14) and MCI (OR, 1.17 per 5-year age difference, 95% CI, 1.09-1.26). Each additional year of education was associated with a decrease in risk of dementia (OR, 0.93 per year of school, 95% CI, 0.89-0.97) and MCI (OR, 0.94, 95% CI, 0.91-0.97). Dementia was more common among non-Hispanic Black individuals (OR, 1.81; 95% CI, 1.20-2.75) and MCI in Hispanic individuals (OR, 1.42; 95% CI, 1.03-1.96) compared with non-Hispanic White individuals. Other group comparisons by race and ethnicity were not possible owing to small numbers. No differences in prevalence were found between female individuals and male individuals. Conclusions and Relevance Using a comprehensive neuropsychological test battery and large sample, the national prevalence of dementia and MCI in 2016 found in this cross-sectional study was similar to that of other US-based studies, indicating a disproportionate burden of dementia and MCI among older Black and Hispanic adults and those with lower education.

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The International Code of Medical Ethics of the World Medical Association

Ramin Walter Parsa-Parsi (2022)

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Guardianship: A medicolegal review for clinicians

Kahli Zietlow, Leslie Dubin, Alethia Battles … (2022)

Guardianship may pose an ethical dilemma for physicians, who must balance protecting vulnerable patients from potential safety concerns with respecting their autonomy. Older adults with dementia are particularly susceptible to loss of independence and the ability to participate in medical decision making. To have the capacity for medical decision making, individuals must understand relevant information, appreciate their circumstances, demonstrate reasoning, and express a consistent choice free from coercion. Although capacity assessments are usually task‐specific, geriatricians and other specialists may be asked to comment on capacity more globally. These determinations may be used to support a Petition for the Appointment of a Guardian of a Legally Incapacitated Adult, the legal process of pursuing guardianship in probate court. Assigned guardians may be known to the incapacitated individual (e.g., a family member or friend) or may be professional guardians with no prior relationship to the ward. Guardians are encouraged to use substituted decision‐making, taking into account the ward's previously expressed values and preferences. Although a number of viable alternatives to guardianship exist, numerous systemic barriers may prevent these from being fully explored. The ongoing need for guardianship should be periodically revisited and reassessed. Data about guardians and wards is shockingly sparse, as there are no centralized databases. Laws and regulations for guardianships vary significantly between states. Physicians can serve as important allies and advocates for patients with cognitive impairment at risk of incapacity, can help preserve their autonomy for as long as possible, and ensure appropriate protections are in place if the patient does lose their decision‐making ability. See related Editorial by Chodos et al . in this issue.

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Author and article information

Journal

Journal ID (nlm-ta): Gerontol Geriatr Med

Journal ID (iso-abbrev): Gerontol Geriatr Med

Journal ID (publisher-id): GGM

Journal ID (hwp): spggm

Title: Gerontology and Geriatric Medicine

Publisher: SAGE Publications (Sage CA: Los Angeles, CA )

ISSN (Electronic): 2333-7214

Publication date (Electronic): 14 December 2023

Publication date Collection: Jan-Dec 2023

Volume: 9

Electronic Location Identifier: 23337214231218581

Affiliations

[1 ]Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, MI, USA

[2 ]VDepartment of Family & Community Medicine and Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA

[3 ]Geriatric Research Education and Clinical Center, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA

[4 ]Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA

Author notes

[*]Linda Wang, DO, University of Michigan, 1500 E Medical Center Dr., Ann Arbor, MI 48109, USA. Email: lgwang@ 123456med.umich.edu

Author information

Linda Wang https://orcid.org/0000-0001-8290-6129

Article

Publisher ID: 10.1177_23337214231218581

DOI: 10.1177/23337214231218581

PMC ID: 10725095

PubMed ID: 38107507

SO-VID: ee45fdec-83e4-4d9c-9a79-013ec17e3dfb

License:

This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License ( https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access page ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

History

Date received : 31 July 2023

Date revision received : 6 November 2023

Date accepted : 17 November 2023

Custom metadata

cover-date January-December 2023

typesetter ts1

Keywords: clinical geriatrics,cognitive impairment,surrogate decision-making,education

Data availability:

Keywords: clinical geriatrics, cognitive impairment, surrogate decision-making, education

Guardianship: The Implications of Resident Physician Perceptions of Caring for Incapacitated Older Adults Without Advocates

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