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A Time to Step In: Legal Mechanisms for Protecting Those with Declining Capacity

Published online by Cambridge University Press:  06 January 2021

Jalayne J. Arias
Jalayne J. Arias*
Affiliation:
Cleveland Fellowship in Advanced Bioethics, Cleveland Clinic
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Extract

Current estimates approximate that the population over sixty-five years of age will increase from 40 million in 2010 to 72.1 million by 2030. As society ages, the number of elderly with cognitive deficits that impair decision-making abilities will also increase. This will place additional burdens on families and probate courts seeking to balance individual autonomy with necessary protections. A legal determination of incompetency is a prerequisite to a judicial order appointing a guardianship or other protective mechanism. The current legal-medical model for competency determinations fails to reflect the complexities of declining capacity in an aging population. A global structure for competency determinations leaves a critical gap between competent and incompetent. The gap between competence and incompetence not only raises concerns about how to classify those that fall between the two, but also highlights the lack of legal protections for those within the gap. A revised model is needed to provide protections to individuals who do not yet meet the threshold for incompetence but require additional protections for their personal or financial welfare. This Article provides an unprecedented examination of the legal model for determining competence through a comparison of the medical model for evaluating capacity. While a number of legal scholars have examined the appointment and oversight of guardians, fewer articles have critically examined the process by which individuals are declared incompetent. This Article presents a comprehensive overview of competency and clinical capacity determination procedures, legal mechanisms available to protect individuals with declining capacity, and policy recommendations for improving legal protections in light of inefficiencies related to legal competency determinations.

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Article
Information
American Journal of Law & Medicine , Volume 39 , Issue 1 , March 2013 , pp. 134 - 159
Copyright
Copyright © American Society of Law, Medicine and Ethics and Boston University 2013

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References

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55 Id. at 219.

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62 KIM, supra note 28, at 21.

63 Appelbaum & Grisso, supra note 58, at 1635.

64 Id.

65 Id. at 1635-36.

66 Id. at 1636.

67 Using this technique, the evaluator may ask the individual questions like, “I just explained your illness, can you tell me what I told you about the diagnosis?” or, “Can you explain your options to me?”

68 Berg et al., supra note 11, at 355.

69 Appelbaum & Grisso, supra note 58, at 1635.

70 KIM, supra note 28, at 22-23; see also Berg et al., supra note 11, at 355.

71 Karlawish, supra note 12, at 94-95.

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77 Berg et al., supra note 11, at 358.

78 KIM, supra note 28, at 26.

79 Id. at 28-32; Brudney, Daniel & Lantos, John, Agency and Authenticity: Which Value Grounds Patient Choice?, 32 THEORETICAL MED. BIOETHICS 217, 217-27 (2011)Google Scholar.

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82 Appelbaum & Grisso, supra note 58, at 1635-36.

83 Id. at 1636.

84 Moye & Marson, supra note 45, at P3. A recent meta-analysis of capacity evaluation tools identified nineteen different instruments for evaluating medical decision-making capacity. Sessums et al., supra note 28, at 422.

85 Kapp & Mossman, supra note 13, at 77.

86 Various clinicians may be qualified to conduct capacity evaluations, including neurologists, psychologists, and psychiatrists. Some clinicians may have received additional experience related to capacity evaluations. Experience in capacity evaluations, however, is a critical component to determining whether a clinician is qualified to conduct the evaluation. ABA COMM’N ON LAW & AGING & AM. PSYCHOLOGICAL ASS’N, ASSESSMENT OF OLDER ADULTS WITH DIMINISHED CAPACITY: A HANDBOOK FOR LAWYERS 32-33 (2005).

87 Sessums et al., supra note 28, at 422; KIM, supra note 28, at 94.

88 KIM, supra note 28, at 94.

89 Id. at 95.

90 See James M. Lai et al., Everyday Decision-Making Ability in Older Persons with Cognitive Impairment, 16 AM. J. GERIATRIC PSYCHIATRY 693 (2008); Marson, Daniel C. et al., Assessing Financial Capacity in Patients with Alzheimer Disease: A Conceptual Model and Prototype Instrument, 57 ARCHIVES NEUROLOGY 877 (2000)Google Scholar; Sessums et al., supra note 28, at 422.

91 Sessums et al., supra note 28, at 422.

92 Id. at 425.

93 Id. at 423.

94 The instrument was developed in an effort to establish measures for assessing capacity for clinical informed consent purposes. KIM, supra note 28, at 99-100. Established measures are “well conceptualized and operationalized in relation to the accepted legal standards.” Id. at 95.

95 Berg et al., supra note 11, at 365.

96 Marson, Daniel C. et al., Assessing the Competency of Patients with Alzheimer's Disease Under Different Legal Standards: A Prototype Instrument, 52 ARCHIVES NEUROLOGY 949 (1995)Google Scholar.

97 Lai et al., supra note 90, at 693.

98 The instrument can be adapted to address specific concerns regarding an individual's capabilities to conduct specific daily living tasks (e.g., abilities to prepare meals, manage medication, and manage meals). Id. at 694.

99 An early study validated the instrument for consistency with convergent tests through a study comparing participants with a range of degrees of capacity. Marson et al., supra note 90, at 808.

100 Sessums et al., supra note 28, at 422.

101 Appelbaum, supra note 22, at 1838; Sessums et al., supra note 28, at 422.

102 Frolik, Lawrence A., Promoting Judicial Acceptance and Use of Limited Guardianship, 31 STETSON L. REV. 735, 745 (2002)Google Scholar.

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105 Following the appointment, judicial oversight is provided as a means of further protection. JUDICIAL DETERMINATION OF CAPACITY, supra note 25, at 14-15.

106 Following the petition, the court will conduct an initial screening to determine whether the case is appropriate for further review. Gavisk & Greene, supra note 20, at 341; Moye, Jennifer et al., Clinical Evidence in Guardianship of Older Adults Is Inadequate: Findings from a Tri-State Study, 47 GERONTOLOGIST 604, 608 (2007)Google Scholar.

107 JUDICIAL DETERMINATION OF CAPACITY, supra note 25, at 8.

108 Gavisk & Greene, supra note 20, at 341.

109 Id.

110 JUDICIAL DETERMINATION OF CAPACITY, supra note 25, at 10.

111 Frolik, supra note 102, at 735.

112 Berg et al., supra note 11, at 348-49.

113 Frolik, supra note 102, at 735.

114 See In re Conservatorship of Groves, 109 S.W.3d 317, 330 (Tenn. Ct. App. 2003) (noting that Tennessee uses the term “disabled person” rather than incompetent or incapacitated).

115 Wright, supra note 7, at 60.

116 Wilber & Reynolds, supra note 103, at 252.

117 See id. at 248.

118 Teaster, Pamela B. et al., Wards of the State: A National Study of Public Guardianship, 37 STETSON L. REV. 193, 196 (2007)Google Scholar.

119 See GN 00502.300: Digest of State Guardianship Laws, SOC. SECURITY ONLINE (Aug. 3, 2012), http://policy.ssa.gov/poms.nsf/lnx/0200502300.

120 NEV. REV. STAT. § 159.022 (2011).

121 See, e.g., Teaster et al., supra note 118, at 207 (showing most states rely less on “specific clinical conditions”).

122 Wright, supra note 7, at 77.

123 Id.

124 See generally McManus, Patricia C., A Therapudential Approach to Guardianship of Persons with Mild Cognitive Impairment, 36 SETON HALL L. REV. 591 (2006)Google Scholar (discussing therapeutic jurisprudence and its impact in court proceedings for people who possess mental impairments).

125 Id. at 592-93.

126 Gavisk & Greene, supra note 20, at 340.

127 Salzman, Leslie, Rethinking Guardianship (Again): Substituted Decision Making as a Violation of the Integration Mandate of Title II of the Americans with Disabilities Act, 81 U. COLO. L. REV. 156, 174 (2010)Google Scholar.

128 Id.

129 Id.

130 Id. at 175.

131 Id.

132 NEV. REV. STAT. § 159.054 (2011) (“If the court finds the proposed ward to be of limited capacity and in need of a special guardian, the court shall enter an order accordingly and specify the powers and duties of the special guardian.”).

133 States may use differing terms for “incompetent,” including incapacitated or disabled. In this section, however, I will use “incompetent” for consistency, unless quoting a specific text.

134 See CAL. PROB. CODE § 811(d) (2012) (“The mere diagnosis of a mental or physical disorder shall not be sufficient in and of itself to support a determination that a person is of unsound mind … .”); UNIF. GUARDIANSHIP & PROTECTIVE PROCEEDINGS ACT § 102(5) (1997) (“[T]he individual lacks the ability to meet essential requirements for physical health, safety, or self-care, even with appropriate technological assistance.”); UNIF. PROBATE CODE § 5-102(4) (1969) (amended 2010).

135 Teaster et al., supra note 118, at 196-98.

136 UNIF. PROBATE CODE § 5-102(4) .

137 See Uniform Probate Code Locator, LEGAL INFO. INST., http://www.law.cornell.edu/uniform/probate.html (last visited Dec. 2, 2012).

138 UNIF. GUARDIANSHIP & PROTECTIVE PROCEEDINGS ACT § 102(5) (“‘Incapacitated person’ means an individual who, for reasons other than being a minor, is unable to receive and evaluate information or make or communicate decisions to such an extent that the individual lacks the ability to meet essential requirements for physical health, safety, or self-care, even with appropriate technological assistance.”).

139 Probate Code Summary, UNIF. LAW COMM’N, http://www.uniformlaws.org/ActSummary.aspx?title=Probate Code (last visited Aug. 16, 2012).

140 ARIZ. REV. STAT. ANN. § 14-5101(1) (2011).

141 Rein, supra note 4, at 1879-80.

142 Id.

143 See id. (“What minor deficiencies or behavioral infractions might be encompassed by the incredibly broad ground ‘other cause’ is anyone's guess.”).

144 Probate judges rarely document reasons for granting guardianship petitions, and guardianship determinations (including competency findings) are rarely appealed, limiting the ability for judges to develop consistent standards or criteria for making these determinations. See id. at 1880.

145 JUDICIAL DETERMINATION OF CAPACITY, supra note 25, at 4-5.

146 Id.

147 Id. at 13.

148 Id. at 13-14.

149 Moye et al., supra note 106.

150 Appelbaum, supra note 22, at 1836.

151 Id.

152 Wright, supra note 7, at 80-81.

153 Id.

154 Id.

155 Moye et al., supra note 106, at 610.

156 Frolik, supra note 102, at 745.

157 While there are numerous inadequacies in the current system, the proposal here maintains that a higher threshold for incompetence remains intact in order to provide plenary guardianships as a mechanism to protect those with serious deficits (e.g., individuals with late stage dementia).

158 While a number of states appoint conservators for financial purposes, here the new model would note an individual's deficits at the competency determination stage, prior to making a determination whether a guardian or conservator should be appointed and identifying the guardian or conservator's role.

159 See, e.g., NEV. REV. STAT. § 159.022 (2011).

160 Gibson, Laura, Giving Courts the Information Necessary to Implement Limited Guardianships: Are We There Yet?, 54 J. GERONTOLOGICAL SOC. WORK 803, 806 (2011)Google Scholar.

161 See id.

162 Further research is needed to identify measures that could improve the quality of clinical reports. Potential measures may include certification of clinicians who are capable and have demonstrated an adequacy in report preparation.

163 Identifying and validating a universal tool for competency evaluations will require additional research and consensus among experts. Experts would include probate judges and attorneys, legal and medical scholars, and other professionals who specialize in guardianship and competency issues relating to neurodegenerative conditions. This will require research regarding the scientific validity of the instrumental and pragmatic considerations (i.e., cost) regarding each instrument or the potential development of a new instrument.

164 See, e.g., Prasun, Pankaj & Misra, Vinod K., Declining School Performance as a Harbinger of a Treatable Neurodegenerative Condition, 260 J. PEDIATRICS 1062 (2012)CrossRefGoogle Scholar.

165 Protective measures would need to be included within the model to prevent clinicians from undue exposure to liability resulting from their role in identifying changes in an individual's abilities for purposes of legal protective measures.

166 See Frolik, supra note 102, at 742-43.

167 See id. at 751.

168 See id. at 747-49.

169 Wright, supra note 7, at 79.

170 A current lack of data makes it difficult to determine why limited guardianships have not been successfully adopted.

171 Frolik, supra note 102, at 752.

172 Id. at 741.

173 Id. at 742.

174 Id. at 743.

175 Id.

176 Id. at 745.

177 See Meyers, Alaya B., Rejecting the Clear and Convincing Evidence Standard for Proof of Incompetence, 87 J. CRIM. L. & CRIMINOLOGY 1016, 1039 (1997)Google Scholar.

178 Frolik, supra note 102, at 749.

179 Id.

180 See id.

181 Rhein, Jennifer L., No One in Charge: Durable Powers of Attorney and the Failure to Protect Incapacitated Principals, 17 ELDER L.J. 165, 170-71 (2009)Google Scholar. For example, a healthcare power of attorney may or may not be authorized to refuse life-sustaining treatment for a patient who lacks capacity.

182 See Salzman, supra note 127, at 180.

183 Id.

184 Id. at 180-82

185 Id.

186 Id. at 232.

187 Id.

188 Id. at 233.

189 See id. at 177. Less restrictive alternatives include informal use of surrogate decision-makers, durable or healthcare power of attorney, community and social services, adult protective services, or representative payees.

190 See generally Richard T. Vanderheiden, Guardianship: Consider the Alternatives, LIFE & TIMES (Nat’l Coll. of Probate Judges, Williamsburg, Va.), Fall 2003, available at http://www.maricopa.gov/pubfid/Documents/Misc/alternate.pdf.

191 Id.; see also UNIF. PROBATE CODE § 5-501 (1969) (amended 2010) (A durable power of attorney designates another person to serve as the legal decision-maker upon losing decision-making capacity).

192 Vanderheiden, supra note 190.

193 Moye & Marson, supra note 45, at P3.

194 Representative Payee Home, SOC. SECURITY, http://www.ssa.gov/payee/ (last updated Oct. 2, 2012).

195 Id.

196 Id.