Guardianship in hospitals: a collaborative pilot project

Waiting for guardianship in a public hospital geriatric inpatient unit: a mixed methods observational case series

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.

Guardianship patient characteristics and outcomes in geriatric social work practice: Australian context

This study explored the patient characteristics and outcomes in relation to guardianship in a large-scale sub-acute Australian hospital. Fifteen patients who appointed a guardian at The Kingston Center, Monash Health, participated through exploratory data collection and analysis utilizing a de-identifiable template. The findings revealed both diverse and complex patient characteristics, and ethical dilemmas in patient outcomes for social workers. Patient outcomes post-guardianship appointment and discharge highlighted a negative impact from long length of stay and the iatrogenic impact on patient wellbeing in hospital. The study reflected a disparity between patients' discharge goals and their outcomes indicating significant ethical dilemmas and complexities for social workers in ensuring rights to autonomy and responsibility for safety are balanced.