Improving Mental Health Guardianship: From Prevention to Treatment

"Get Well Enough to Make the Right Decision for Themselves"-Experiences and Perspectives of Clinicians Working with People with Serious Mental Illness and Their Substitute Decision Makers

In the current clinical psychiatric practice in most of the world, treatment decisions are based on a person's capacity to make these decisions. When a person lacks the capacity to understand and appreciate treatment decisions, in many jurisdictions a third-party substitute decision maker (SDM) is appointed on his or her behalf in order to promote safety and optimal clinical outcome. In Ontario, Canada, for example, family members (typically) or public guardians are appointed as SDMs, and they form an integral part of the medical-legal system in psychiatric care. Clinicians working with both patients and their SDMs in these circumstances encounter unique challenges and deliver care in specialized ways, though little research has focused on their experiences and reflections. Based on focus group data, this qualitative study uses a descriptive and interpretative phenomenological approach through thematic analysis to examine these aspects from clinicians working in both inpatient and outpatient settings of an urban teaching hospital's psychiatric services in Toronto, Canada. Seven key themes emerged: Clinicians (1) appreciate hardships and challenges in lives of SDMs and patients-including the challenging emotions and experiences on both sides, and the risks and relational changes from being an SDM; (2) have an understanding of the patient's situation and respect for patient autonomy and wishes-they are promoter of autonomy and mindful of patients' prior wishes amidst patients' fluctuating capacity, facilitating communication, keeping patients informed and promoting transitioning from SDM to self-determination; (3) have a special working relationship with family SDMs-including supporting SDMs, avoiding harm from delayed or denied treatment, and educating and collaborating with SDMs while maintaining professional boundaries; (4) at times find it difficult working with SDMs-stemming from working with over-involved or uninterested family SDMs, coping with perceived poor SDM decisions, and they sometimes ponder if SDMs are necessary; (5) delineate differences between family and Public Guardian and Trustee (PGT) SDMs-they see PGT as closely aligned with medical decision makers, while family SDMs are more intimately involved and more likely to disagree with a physician's recommendation; (6) recognize the importance of the SDM role in various contexts-through seeing social values in having SDMs, and acknowledging that having SDMS help them to feel better about their actions as they work to protect the patients; and (7) express ideas on how to improve the current system-at public, societal, and family SDM levels. We conclude that clinicians have unique mediating roles, with privilege and responsibility in understanding the different roles and challenges patients and SDMs face, and have opportunities to improve patient and SDM experiences, clinical outcomes, carry out education, and advocate for ethically just decisions. These clinical roles also come with frustration, discomfort, moral distress and at times vicarious trauma. Clinicians' unique understanding of this complex and nuanced intersection of patient care provides insight into the core issues of autonomy, duty to care and protect, advocacy, and emotional dynamics involved in this sector as a larger philosophical and social movement to abolish SDMs, as advocated by the Convention on the Rights of Persons with Disability (CRPD), is taking place. We briefly discuss the role of supported decision making as an alternative as.

The Impact of a Guardianship Social Worker on Inpatient Time-To-Guardianship and Costs: Preliminary Findings

Unrepresented patients who lack decision-making capacity can remain in hospitals for weeks awaiting guardianship and subsequent discharge, resulting in medically unnecessary and costly extended stays. The guardianship process is complicated and requires collaboration between the medical and legal systems. The Rocky Mountain Regional Veteran Affairs Medical Center created a guardianship social worker position to improve the guardianship process by developing subject matter expertise, infrastructure, and standardized procedures. In this brief report, we provide preliminary data on the impact of a guardianship social worker. Time to guardianship completion, mean lengths of stay (LOS), counts of completed guardianships, and cost estimates were compared before and after the guardianship social worker position was created. The mean time to complete guardianships decreased from 121.9 to 69.8 days (p = .13), the mean LOS for patients awaiting guardianship decreased from 129.8 to 117.2 days (p = .39), and the yearly counts of completed guardianships increased from 2 to 9 (p = .002). Estimated inpatient cost savings per patient was $56,244. While promising, these preliminary data are limited by small case numbers and the unknown impact of the COVID-19 pandemic on long-term placement. Creating guardianship-focused social work positions has the potential to create efficiencies in the guardianship process.

Addressing Mental Health Disability in Unsheltered Homelessness: Outpatient Conservatorship in Los Angeles

OBJECTIVE

The authors sought to describe a pilot program for gravely disabled individuals experiencing unsheltered homelessness in Los Angeles County that illustrates a promising public health framework to address mental health-related disability in homeless populations.

METHODS

Homeless outreach teams implementing the outpatient conservatorship (OPC) pilot program adopted a population health approach, multisystem care coordination, and prioritization of the least restrictive environments. The program allowed initiation of a Lanterman-Petris-Short (LPS) conservatorship outside of a hospital, with the goal of serving highly vulnerable individuals in the least restrictive settings. Between August 2020 and July 2021, the OPC pilot program served 43 clients, corresponding to 2% of those served by the outreach teams during that period. Using observational program evaluation data, the authors examined the impact of the program on this sample of participants.

RESULTS

At 12 months, 81% of OPC clients were no longer experiencing unsheltered homelessness; 65% accessed an LPS conservatorship. Although most OPC clients utilized a psychiatric hospital, 54% left locked settings earlier than would have been possible without the program. One-third of clients referred for LPS conservatorship used unlocked licensed residential facilities in the first year. Negative events, such as remaining in unsheltered homelessness, were more common among clients not referred for LPS conservatorship.

CONCLUSIONS

Timely receipt of street-based services and coordination of care before, during, and after referral for LPS conservatorship reduced use of restrictive settings. The OPC program's components constitute a promising triadic framework for addressing mental health disability among unsheltered individuals that warrants further investigation.

"Everyone means well but the one person who's really going to go to bat" - experiences and perspectives of substitute decision makers in caring for their loved ones with serious mental illness

In the era of on-going efforts to empower persons with mental illness to be independent decision makers as informed by the United Nations' Convention on the Rights of Persons with Disability (CRPD), family members acting as substitute decision makers (SDM) for people suffering from disabling serious mental illness (SMI) remain an integral part of the medical-legal system in psychiatric care in many parts of the world, including Canada; yet their experiences and perspectives are rarely studied. This explorative qualitative study examines the lived experiences and reflections of 14 family member SDMs in Toronto, Canada. Five key themes related to being SDM emerged: 1) Varied subjective understanding of the responsibility and authority of the SDM role; 2) Varied role demands and impact on SDMs' lives; 3) Challenges in dealing with the mental health system; 4) Leveraging decision making status to promote patient care; and 5) SDM role impact on family relationships. The need to improve SDM understanding of their role, acknowledging their value and care-taker burden, finding a balance for their involvement, and improving their support in efforts to enhance care for the patients are discussed.