Person-Centered Guardianship Between Strangers

It is widely understood that the ethical practice of guardianship includes safeguarding the autonomy of the individual while supporting the health, safety, and happiness as much as possible in the way that the person defines it. This is what is meant by person-centered guardianship: a respectful balance of stepping in and stepping out, so that support is not smothering or coercive. Often, this comes naturally to family-member guardians guided by love. There is also a growing body of training, educational materials, and support groups, such as those sponsored by the Center for Guardianship Excellence, ^[1] that family guardians can access in order to deepen their understanding and more effectively offer support that centers on the whole person.

Stranger Guardianship

The question we raise in this article is how guardianship can be person-centered when the incapacitated person and the guardian are complete strangers, unknown to one another prior to the appointment. This is the situation for about a third of the guardianships in Massachusetts.^{<a href=”#footnote-2″> [2]</a>} It is the result of a confluence of incapacity, poverty, and social isolation in a situation of immanent risk of personal or financial harm to the individual or to others. We refer to it here as “stranger guardianship.”

The more complex the functional limitations and needs of the individual, the more challenging it is to balance helpful intervention against respectful distance. For example, my organization, Public Guardian Services (PGS), worked with the Department of Developmental Services (DDS) to transition an individual in his mid-50’s from a nursing home to a group home, where he would have more potential friendships and certainly more freedom. PGS had been this person’s guardian for about three years, so it was no longer a relationship of complete strangers. But neither was it informed by a long family history.

While it looked good on paper, this plan failed because the man’s loss of impulse control (caused by the brain injury he had suffered years before) triggered him to assault staff and residents at the group home a number of times. Despite heroic efforts and patience of the part of DDS, the man went back to the nursing home after four or five attempts over several months. Would a family guardian have had more success? There is no way to know.

Balancing intervention against non-intervention is difficult when the person’s needs are extreme, but especially when the guardian and the individual are strangers who probably have no reason to know each other at all, except that they have been placed in a court-appointed relationship. Unfamiliarity is a problem not just for the guardian, but also for the individual who has been thrust involuntarily into this new situation.

Getting Acquainted

The guardian’s essential first move is to interact enough with the person to identify support needs. There is a period of acquaintance. During this time, it will be useful to assess needs across areas of normal life experience, such as the following:

1. Medical health: Ascertain, prioritize and step in, if needed, to make necessary medical referrals. Some individuals may need the guardian or a trained care provider to go along on visits in order to communicate information about the person and to report accurately how the visit or treatment went. Find out if the person has a preference about this.
2. Behavioral health: Spend time with the individual, read the medical chart, and ask what, if anything, the individual believes may be his or her mental health needs. Confer with treating professionals about what the most effective role of the guardian may be. Be mindful of HIPAA rules and aim for agreement with the person about how much the guardian should disclose and to whom.
3. Material well-being: Learn the individual’s preferences for housing or residential care; what kinds of food he or she prefers; clothing preferences; attitudes toward friendship and social life; level of competence with money, banking, and bill-paying; and other material aspects of daily life. Where preferences are strong and the choices reasonable, advocate for the person. Be as circumspect as possible when having to override an unsafe or impossible choice.
4. Life Enhancement and Growth: Ask the person about his or her hobbies, work history, educational history and interests, travel experience or desires, interest in sports or entertainment, interest in spiritual practice or growth, and any other areas of life that come up. Assess the person’s capacity for independent self-care and the ability to maintain a household, with or without assistance.
5. Restoration of Rights: Offer information about restoration of rights in a form that the person can understand and see how he or she responds. Make a point to observe whether the person is independent enough in some areas to limit the guardianship, or if appropriate, to terminate it. Take every request to restore rights seriously.

What To Expect

The kind of relationship that develops after the initial steps of getting acquainted is impacted by how both parties respond. The guardian needs to be alert to how the individual may feel about having a guardian at all, which can affect the relationship in many ways. The inequality of power in the relationship may be a factor, which usually is best handled by acknowledging that it is a fact and turning, as much as possible, to what the individual sees as his or her own priorities.

If the individual is not able to interact verbally, the guardian has a duty to learn how the person communicates or how to interpret nonverbal behavior. The guardian must develop an understanding of the individual’s needs and preferences on the basis of whatever communication is possible.

Access to supervision can be indispensable to a guardian in developing the relationship, especially if it does not start out well. In extreme cases, the guardian may find it helpful to study the clinical conditions that contribute to the individual’s incapacity so as to better understand him or her, especially if the person is nonverbal or lacks the kind of memory that is needed to build a normal relationship.

Models and Skills of Guardianship

The Massachusetts Guardianship Policy Institute and others have offered classifications that identify commonalities among guardianship relationships in certain situations, such as a distinction between a social-work model and a “decisions-only” model. These models largely concern levels of engagement that are involved in providing for the well-being of an individual. The social work model, for example, emphasizes that needs are interrelated and that specific needs, such as medical care, cannot be addressed if the individual’s housing, behavioral health, or material well-being are grossly inadequate.

Ultimately, however, a guardian who chooses a person-centered approach takes cues from the individual to calibrate the right balance of intervention and respectful distance so as to address the person’s actual needs, options, and preferences. Family guardians usually have information about the individual, and possibly a shared history, that speeds up this process; stranger guardians, by definition, do not. Nevertheless, a guardian who invests time with a stranger in this situation has the best chance of establishing a balanced relationship of support that is helpful to the individual and rewarding to the guardian.