April 01, 2014

A Guardian’s Health Care Decision-Making Authority: Statutory Restrictions

Karna Sandler

(Note: The pdf for the issue in which this article appears is available for download: BIFOCAL Vol. 35, Issue 4. The issue's pdf includes a summary table of findings. Readers my also be interested in the author's in-depth table illustrating Statutory Restrictions on Guardianship Health Care Decision-Making.)

 

INTRODUCTION

Guardianship is an import tool for protecting incapacitated adults who are unable to care for themselves. One role of the guardian is to make or assist the individual with health care decisions, ranging from routine appointments to serious surgical procedures and end-of-life decisions. To ensure guardian accountability in these highly personal decisions,1 some states have statutory restrictions that require court approval for certain critical health care decisions that “implicate . . . the ward’s most fundamental privacy and liberty interests.”2 These restricted decisions may include placing an individual in a mental health or residential facility, consenting to invasive or experimental procedures, or withholding life-sustaining treatment. 

Although this article only addresses state guardianship statutes, other types of statutes also may include restrictions on health care decision-making by guardians. Default surrogate consent statutes (sometimes called “family consent” statutes) address decision-making authority in the event an individual lacks capacity to make health care decisions and there is no advance directive. Generally, these statutes list a hierarchy of individuals who may be authorized to serve as a surrogate decision-maker, which may include a guardian. In addition, involuntary commitment statutes and power of attorney statutes may address certain areas of guardianship decision-making. However, these statutes are beyond the scope of this article.

This article updates a portion of a 2003 article titled Health Care Decision-Making: A Guardian’s Authority by Sarah B. Richardson.3 State statutory restrictions on guardianship health care decision-making have changed little since 2003. Nevertheless, the changes show a small trend towards states increasing the number of restricted decisions; in particular restrictions on placement in mental health facilities, consent to invasive procedures, and consent to withholding or withdrawing life-sustaining treatment. This article provides a comparison of state statutory restrictions on guardianship health-care decision making and analyzes how those restrictions have changed in the last ten years.

STATUTORY RESTRICTIONS

State guardianship statutes generally grant guardians broad authority to make health care decisions for incapacitated persons and contain language similar to the Uniform Guardianship and Protective Proceedings Act (“UGPPA”), which states that a guardian may “consent to medical or other care, treatment, or service for the ward.”4 However, the statutes limiting that authority vary broadly and only eight states have no statutory restrictions on guardianship healthcare decision-making.5 

Admission to a Mental Health Facility

Placement in a mental health facility greatly restricts an individual’s freedom by segregating the individual from mainstream society.6 Thus, all states require a civil commitment process for involuntary placement in a mental health facility. However, it can be unclear whether a guardian has the authority to “voluntarily” place an individual in a mental health facility, without going through the civil commitment process. 7

Thirty state guardianship statutes follow the UGPPA, which states “a guardian may not initiate the commitment of a ward to a mental health-care institution except in accordance with the State’s procedure for involuntary civil commitment.”8 However, four of those states make an exception allowing guardians to place incapacitated persons in mental health facilities without court approval for a limited time period, ranging from two to forty-five days.9 By requiring court approval, states add a layer of protection to ensure that the decision is made appropriately. 

Admission to a Residential Care Facility

Residential care facilities are institutions that provide long-term care in a residential setting, such as nursing homes and assisted living facilities. Like mental health facilities, residential care facilities are restrictive settings that can be very isolating for the individual.10 Consequently, some states also restrict a guardian’s authority to place individuals in residential care facilities.

Eleven states require court approval for a guardian to place an incapacitated person in a residential care or nursing facility.11 However, Nevada makes an exception for when a guardian obtains the recommendation of a physician or other certified person.12 Furthermore, although Maryland’s and Iowa’s statutes do not specifically address residential care or nursing facilities, Maryland requires court approval for a change in classification of abode; and Iowa requires court approval for placement in a more restrictive setting.13 These restrictions all serve to protect the individual from the potentially isolating effects of a residential care facility unless necessary for the individual’s well-being.

Consent to Invasive Procedures

Although guardians generally have the authority to consent or withhold consent to medical procedures on behalf of the incapacitated individual, some states find that certain invasive procedures require extra oversight by the court. These procedures are controversial because of the personal nature of the decision, which involves an individual’s moral, ethical and religious beliefs. Delegating the authority to guardians creates a risk that a guardian might impose the guardian’s own beliefs into the decision-making process. Moreover, these procedures are of additional concern because of the potential negative impact on an individual’s mental health. Therefore, some states require court approval for controversial invasive procedures.

Nineteen states have provisions restricting the guardian’s ability to consent on behalf of the incapacitated person to one or more invasive procedures, including abortion, sterilization, psychosurgery, or removal of bodily organs.14 However, states vary as to which of these decisions are restricted, with only five states restricting consent to all four procedures.15 Seventeen states restrict consent to sterilization,16 thirteen states restrict consent to psychosurgery,17 nine states restrict consent to abortion,18 and seven states restrict consent to the removal of bodily organs.19 Two states have also added amputation to the list of restricted procedures.20 Iowa takes a broader approach and prohibits a guardian from consenting to any major elective surgery or non-emergency major medical procedure, without court approval.21 Most states always require court approval for these invasive procedures; however, seven states make an exception for emergency situations in which the procedure is necessary to preserve life or prevent serious harm.22

Consent to Experimental Treatment

The decision to consent to experimental treatment is complex because of the uncertainty involved. Thus, the decision requires a number of important considerations, such as the likelihood of success, possibility of side-effects, availability of other treatment options, and the benefits to science. Therefore, some states find that the decision to consent to experimental treatment requires additional protections. 

Twelve states require court approval before a guardian may consent on behalf of the incapacitated person to experimental treatment.23 However, some of those states allow guardians authority to consent to experimental treatment in limited circumstances. California only limits the use of experimental drugs, not experimental procedures.24 Furthermore, Arkansas makes an exception for experimental treatments that are intended to preserve life or prevent serious harm, and Wisconsin makes an exception for experimental treatment that involves a minimal risk of harm.25 By requiring court approval, these statutes help to ensure that the complexities of the decision are taken into consideration. 

Consent to Withhold or Withdraw Life-Sustaining Treatment

Decisions to withhold or withdraw life-sustaining treatment are controversial and involve a number of considerations, such the possibility of improved health, relief from suffering, and the individual’s values, moral, and religious beliefs. Consequently, some courts are hesitant to provide guardians with the authority to make such decisions and instead require court approval or proscribe specific standards to use in making the determination. 

Fourteen state guardianship statutes address a guardian’s authority to make decisions about whether to withhold or withdraw life-sustaining treatment.26 Eleven of those states prohibit the guardian from consenting to withhold or withdraw life-sustaining treatments.27 Nevertheless, five of these states have limited exceptions that allow the guardian to make the decision without court approval when the incapacitated person has provided an advance directive, durable power of attorney, or instructions from the incapacitated person when the incapacitated person had capacity.28 When court approval is required, the statutes generally provide the court with specific standards to use in making the determination to withhold or withdraw life sustaining treatment. 

Three state guardianship statutes have provisions granting guardians the authority to make decisions to withhold or withdraw life-sustaining treatment.29 However, Illinois and Oregon limit that authority to specific situations, such as a terminal condition or permanent unconsciousness.30 The majority of states do not address end-of-life decisions in the state’s guardianship statute, but additional guidance may be available in the state’s default surrogate consent statute.

Consent to Mental Health Treatment

Some states find that certain mental health treatments require additional oversight by the court because of the high risk involved and the controversial nature of the treatments. Accordingly, eight states require court approval before a guardian may consent on behalf of the incapacitated person to convulsive treatment. 31 In addition, Wisconsin restricts a guardian’s authority to consent to the involuntary administration of psychotropic medication.32 

Involuntary Medical Decisions

New Jersey and Vermont take a different approach to restricting a guardian’s authority to make healthcare decisions. Instead of prohibiting the guardian from authorizing specific types of medical decisions, New Jersey requires court approval if the incapacitated person objects to any decision made by the guardian,33 and Vermont requires court approval for consent to any involuntary treatment or medication.34 This approach focuses on the incapacitated individual’s opinion rather than the type of medical decision.

CONCLUSION

States generally provide guardians with broad statutory authority to make healthcare decisions for individuals under their care. However some states limit that authority for medical decisions that are particularly controversial or implicate greater infringements on personal freedoms. For such decisions, state guardianship statutes may require court approval, but these restrictions vary broadly across states. 

A large majority of states have at least one restriction on a guardian’s authority to make health care decisions, and some states restrict as many as eight types of health care decisions. Moreover, there appears to be a small upward trend in states adding new restrictions to guardianship statutes. Although more restrictions add burdens to the guardianship process, states balance this burden against the importance of preserving the individual’s autonomy. Therefore, guardians must be aware of the limits of their authority and when court approval is required for certain critical health care decisions.

 

1 See Mary Joy Quinn, Guardianship of Adults: Achieving Justice, Autonomy, and Safety 17-18 (2005).

2 Kim Dayton, Standards for Health Care Decision-Making: Legal and Practical Considerations, 2012 Utah L. Rev. 1329, 1372 (2012).

3 See Sarah B. Richardson, Health Care Decision-Making: A Guardian’s Authority, 24 Bifocal, No. 4 (Summer 2003).

4 Unif. Guardianship & Protective Proc. Act 1997 § 315.

5 The eight states without statutory restrictions on guardian healthcare decision-making authority are Alabama, Georgia, Idaho, Nebraska, Ohio, Rhode Island, South Carolina, and Utah. Since 2003, only New Jersey added restrictions to its guardianship statutes where it previously had none. N.J. Stat. Ann. § 3B:12-57.

6 Leslie Salzman, Guardianship for Persons with Mental Illness – A legal and Appropriate Alternative? 4 St. Louis U.J. Health L. & Pol’y 279, 293-98 (2011).

7 Naomi Karp and Erica Wood, Choosing Home For Someone Else: Guardian Residential Decision Making. 2012 Utah L. Rev. 1445, 1480 (2012).

8 Unif. Guardianship & Protective Proc. Act 1997 § 316; Alaska Stat. § 13.26.150; Ariz. Rev. Stat. § 14-5312.01; Ark. Code Ann. § 28-65-303; Cal. Prob. Code § 2356; Colo. Rev. Stat. Ann. § 15-14-316; Conn. Gen. Stat. Ann. § 45a- 656; Del. Code Ann. tit. 12, § 3922; D.C. Code Ann. § 21-2047.01; Fla. Stat. Ann. § 744.3215; Haw. Rev. Stat. § 560:5-316; 755 Ill. Comp. Stat. § 5/11a-17; Kan. Stat. Ann. § 59-3075; La. Code Civ. Proc. Ann. art. 4566; Md. Code Ann., Est. & Trusts § 708; Mass. Gen. Laws Ann. ch. 190B, § 5-309; Minn. Stat. Ann. § 524.5-315; Mo. Ann. Stat. § 475.120; Mont. Code Ann. § 72-5-322; N.H. Rev. Stat. Ann. § 464-A:25; N.J. Stat. Ann. § 3B:12-56; N.Y. Mental Hygiene Law § 81.22; N.D. Cent. Code Ann. § 30.1-28-12 (5-312); Okla. Stat. Ann. tit. 30, § 3-119; Or. Rev. Stat. § 125.320; 20 Pa. Cons. Stat. Ann. § 5521; Tex. Est. Code § 1151.053; Vt. Stat. Ann. tit. 14, § 3074; Wash. Rev. Code Ann. § 11.92.043; Wis. Stat. Ann. § 54.25; Wyo. Stat. Ann. § 3-2-202. Three states added this restriction since 2003: Hawaii, Minnesota, and New Jersey. See Sarah B. Richardson, Health Care Decision- Making: A Guardian’s Authority, 24 Bifocal, No. 4 (Summer 2003).

9 Ariz. Rev. Stat. § 14-5312.01 (48 hours); N.H. Rev. Stat. Ann. § 464-A:25 (36 hours); Mo. Ann. Stat. § 475.120 (30 days); N.D. Cent. Code Ann. § 30.1-28-12 (45 days).

10 Naomi Karp and Erica Wood, Choosing Home For Someone Else: Guardian Residential Decision Making. 2012 Utah L. Rev. 1445, 1476 (2012).

11 Cal. Prob. Code § 2356.5; Conn. Gen. Stat. Ann. § 45a656b; 755 Ill. Comp. Stat. § 5/11a-14.1; Kan. Stat. Ann. § 59-3075; La. Code Civ. Proc. Ann. art. 4566; Me. Rev. Stat. Ann. tit. 18-A, § 5-312; Mass. Gen. Laws Ann. ch. 190B, § 5-309; Nev. Rev. Stat. Ann. § 159.0805; N.H. Rev. Stat. Ann. § 464-A:25; Vt. Stat. Ann. tit. 14, § 3073; Wis. Stat. Ann. § 54.25.

12 Nev. Rev. Stat. Ann. § 159.0805.

13 Iowa Code Ann. § 633.635; Md. Code Ann., Est. & Trusts § 13-708.

14 Alaska Stat. § 13.26.150(e); Ark. Code Ann. § 28-65-302(a); D.C. Code Ann. § 21-2047.01(1); Haw. Rev. Stat. § 560:5-602; 755 Ill. Comp. Stat. § 5/11a-17.1; Kan. Stat. Ann. § 59-3075(e); Ky. Rev. Stat. Ann. § 387.660(3); La. Code Civ. Proc. Ann. art. 4566(G); Minn. Stat. Ann. § 524.5-313(c); Nev. Rev. Stat. Ann. § 159.0805(1); N.H. Rev. Stat. Ann. § 464-A:25(I)(c); N.C. Gen. Stat. § 35A-1241(a)(3); N.D. Cent. Code Ann. § 30.1-28-12(4); Okla. Stat. Ann. tit. 30, § 3-119(3); Or. Rev. Stat. § 127.540; 20 Pa. Cons. Stat. Ann. § 5521(d); Vt. Stat. Ann. tit. 14, § 3074(3); Wash. Rev. Code Ann. § 11.92.0423(5); Wyo. Stat. Ann. § 3-2-202(a).

15 Alaska Stat. § 13.26.150(e); Ark. Code Ann. § 28-65-302(a); D.C. Code Ann. § 21-2047.01(1); Ky. Rev. Stat. Ann. § 387.660(3); 20 Pa. Cons. Stat. Ann. § 5521(d).

16 Alaska Stat. § 13.26.150(e); Ark. Code Ann. § 28-65-302(a); D.C. Code Ann. § 21-2047.01(1); Haw. Rev. Stat. § 560:5-602; 755 Ill. Comp. Stat. § 5/11a-17.1; Kan. Stat. Ann. § 59-3075(e); Ky. Rev. Stat. Ann. § 387.660(3); La. Code Civ. Proc. Ann. art. 4566(G); Minn. Stat. Ann. § 524.5-313(c); Nev. Rev. Stat. Ann. § 159.0805(1); N.H. Rev. Stat. Ann. § 464-A:25(I)(c); N.C. Gen. Stat. § 35A-1241(a)(3); N.D. Cent. Code Ann. § 30.1-28-12(4); Or. Rev. Stat. § 127.540; 20 Pa. Cons. Stat. Ann. § 5521(d); Vt. Stat. Ann. tit. 14, § 3074(3); Wyo. Stat. Ann. § 3-2-202(a). Since 2003, only Illinois and Vermont added restrictions on sterilization. See Sarah B. Richardson, Health Care Decision-Making: A Guardian’s Authority, 24 Bifocal, No. 4 (Summer 2003).

17 Alaska Stat. § 13.26.150(e); Ark. Code Ann. § 28-65-302(a); D.C. Code Ann. § 21-2047.01(1); Kan. Stat. Ann. § 59- 3075(e); Ky. Rev. Stat. Ann. § 387.660(3); Minn. Stat. Ann. § 524.5-313(c); N.H. Rev. Stat. Ann. § 464-A:25(I)(c); N.D. Cent. Code Ann. § 30.1-28-12(4); Okla. Stat. Ann. tit. 30, § 3-119(3); Or. Rev. Stat. § 127.540; 20 Pa. Cons. Stat. Ann. § 5521(d); Wash. Rev. Code Ann. § 11.92.0423(5); Wyo. Stat. Ann. § 3-2-202(a). Since 2003, only Oregon added restrictions on psychosurgery. See Sarah B. Richardson, Health Care Decision-Making: A Guardian’s Authority, 24 Bifocal, No. 4 (Summer 2003).

18 Alaska Stat. § 13.26.150(e); Ark. Code Ann. § 28-65-302(a); D.C. Code Ann. § 21-2047.01(1); Ky. Rev. Stat. Ann. § 387.660(3); La. Code Civ. Proc. Ann. art. 4566(G); N.D. Cent. Code Ann. § 30.1-28-12(4); Okla. Stat. Ann. tit. 30, § 3-119(3); Or. Rev. Stat. § 127.540; 20 Pa. Cons. Stat. Ann. § 5521(d). Since 2003, only Oregon added restrictions on abortion. See Sarah B. Richardson, Health Care Decision-Making: A Guardian’s Authority, 24 Bifocal, No. 4 (Summer 2003).

19 Alaska Stat. § 13.26.150(e); Ark. Code Ann. § 28-65-302(a); D.C. Code Ann. § 21-2047.01(1); Kan. Stat. Ann. § 59- 3075(e); Ky. Rev. Stat. Ann. § 387.660(3); Okla. Stat. Ann., tit. 30 § 3-119(3); 20 Pa. Cons. Stat. Ann. § 5521(d).

20 Kan. Stat. Ann. § 59-3075(e); Ky. Rev. Stat. Ann. § 387.660(3).

21 Iowa Code Ann. § 633.635(2).

22 Alaska Stat. § 13.26.150(e); Ark. Code Ann. § 28-65-302(a); D.C. Code Ann. § 21-2047.01(1); Haw. Rev. Stat. § 560:5-602; Kan. Stat. Ann. § 59-3075(e); Ky. Rev. Stat. Ann. § 387.660(3); Okla. Stat. Ann. tit. 30, § 3-119(3).

23 Alaska Stat. § 12.26.150(e); Ark. Code Ann. § 28-65-302(a); Cal. Prob. Code § 2356(b); D.C. Code Ann. § 21- 2047.01(2); Kan. Stat. Ann. 59-3075(e)(6); Minn. Stat. Ann. § 524.5-313(c); Nev. Rev. Stat. Ann. § 159.0805(1); N.H. Rev. Stat. Ann. § 464-A:25(I)(c); N.D. Cent. Code Ann. § 30.1-28-12(4); Okla. Stat. Ann. tit. 30, § 3-119(3); 20 Pa. Cons. Stat. Ann. § 5521(d)(3); Wis. Stat. Ann. § 54.25(2)(d).

24 Cal. Prob. Code § 2356(b).

25 Ark. Code Ann. § 28-65-302(a); Wis. Stat. Ann. § 54.25(2)(d). Since 2003, only Wisconsin has added a statutory provision on experimental treatment. See Sarah B. Richardson, Health Care Decision-Making: A Guardian’s Authority, 24 Bifocal, No. 4 (Summer 2003).

26 Alaska Stat. § 13.26.150; Ariz. Rev. Stat. § 14-5303; Ark. Code Ann. § 28-65-302; D.C. Code Ann. § 21-2047.01; 755 Ill. Comp. Stat. § 5/11a-17; Iowa Code Ann. § 633.635; Kan. Stat. Ann. § 59-3075; Me. Rev. Stat. Ann. tit. 18- A, § 5-312; Md. Code Ann., Est. & Trusts § 13-708; Mont. Code Ann. § 72-5-321; N.Y. Surr. Ct. Proc. Act § 1750-b; Okla. Stat. Ann. tit. 30, § 3-119; Or. Rev. Stat § 125.315; Vt. Stat. Ann. tit 14, § 3075.

27 Alaska Stat. § 13.26.150; Ark. Code Ann. § 28-65-302; D.C. Code Ann. § 21-2047.01; Iowa Code Ann. § 633.635; Kan. Stat. Ann. § 59-3075; Me. Rev. Stat. Ann. tit. 18-A, § 5-312; Md. Code Ann., Est. & Trusts § 13-708; Mont. Code Ann. § 72-5-321; N.Y. Surr. Ct. Proc. Act § 1750-b; Okla. Stat. Ann. tit. 30, § 3-119; Vt. Stat. Ann. tit 14, § 3075. Since 2003, only Montana and Vermont have added these restrictions. See Sarah B. Richardson, Health Care Decision-Making: A Guardian’s Authority, 24 Bifocal, No. 4 (Summer 2003).

28 D.C. Code Ann. § 21-2047.01; Kan. Stat. Ann. § 59-3075; Me. Rev. Stat. Ann. tit. 18-A, § 5-312; Okla. Stat. Ann. tit. 30, § 3-119; Vt. Stat. Ann. tit 14, § 3075.

29 Ariz. Rev. Stat. § 14-5303; 755 Ill. Comp. Stat. § 5/11a-17; Or. Rev. Stat § 125.315.

30 755 Ill. Comp. Stat. § 5/11a-17; Or. Rev. Stat § 125.315.

31 Cal. Prob. Code § 2356(c); D.C. Code Ann. § 21-2047.01(2); Minn. Stat. Ann. § 524.5-3.13(c); N.H. Rev. Stat. Ann. § 464-A:25(I)(c); Or. Rev. Stat. § 127.540(1); 20 Pa. Cons. Stat. Ann. § 5521(d); Wash. Rev. Code Ann. § 11.92.043(5); Wyo. Stat. Ann. § 3-2-202(a). No states have made changes to this requirement since 2003. See Sarah B. Richardson, Health Care Decision-Making: A Guardian’s Authority, 24 Bifocal, No. 4 (Summer 2003).

32 Wis. Stat. Ann. § 54.25(2)(d).

33 N.J. Stat. Ann. § 3B:12-56.

34 Vt. Stat. Ann. tit. 14, § 3074

Karna Sandler

About the Author: Karna Sandler is a second-year law student at American University Washington College of Law in Washington, D.C. Ms. Sandler received her B.A. from Tulane University in New Orleans, LA, with a major in sociology and a minor in Spanish. She is an intern with the Commission on Law and Aging in Washington, DC.