Connolly J, Peisah C. Waiting for guardianship in a public hospital geriatric inpatient unit: a mixed methods observational case series.
Intern Med J 2023;
53:1339-1346. [PMID:
36031739 DOI:
10.1111/imj.15916]
[Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 08/18/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND
Patients in acute hospital settings waiting for guardianship and financial management (FM) hearings experience extended length of stay (LOS), with known consequences for frail elderly. This, together with universal agreement that substitute decision-making is a last resort measure, an imperative exists to examine guardianship and FM applications made from within hospital for geriatric inpatients.
AIMS
This study aims to examine processes around Guardianship applications in a public hospital Geriatric inpatient setting including times to, reasons for and outcomes of referral; and to explore the content of the medical records in relation to criteria for application.
METHOD
This was a mixed methods observational case series using descriptive data supplemented by qualitative case-note analysis of inpatients referred for guardianship (with/without FM) from 2018 to 2020 in a New South Wales Geriatric Medicine inpatient unit. Medical records were examined for evidence of operationalised criteria for guardianship, aligned with disability, capacity and need/risk common to most Australian jurisdictions.
RESULTS
Of 45 patients with guardianship applications, 98% were granted guardians and 33 of 37 (89%) FM applications. Multiple risks underpinned applications, most commonly frequent falls (49%) and medication mismanagement (49%). Although only 29% were in receipt of services preadmission, 98% were discharged to residential care. Average hospital LOS was 70 days (interquartile range, 35), contributed to by delays between admission and decision to apply for guardianship/FM (median, 28 inpatient days) and uncertainties around or lack of documented capacity assessments.
CONCLUSION
This study identifies potential points along pathways towards guardianship in hospital settings, which might be targeted to streamline if not divert some of these applications. Points of intervention include at initiation of applications, with consideration of alternatives to substitute decision-making by addressing patient needs and using supported decision-making, while improving clinician understanding of capacity assessment and guardianship.
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