Guardian of the Gaunt and Gray 

Public guardians must weave the ultimate safety net for those adults who are the most alone, the most vulnerable.

Soon after my family moved to Berkeley, we met a gaunt man who paced up and down our street, muttering obscenities. My three-year-old and I used to see him on our way to preschool in the morning. "Bad man," my son would say, pressing close to me.

"No, his name is John," I would say. The neighbors had told me John's name and his story. Apparently his father, who was his official caretaker, paid the owner of our neighborhood store to keep an eye on him and give him his medicine. That explained why I had seen him sweeping the store. It had made me wonder why they would employ a disheveled person who didn't make eye contact.

It's been years, but I thought of "Big John" for the first time in a while during a recent visit to the office of the Public Guardian of Alameda County. John doesn't haunt our street anymore and I don't know what ever became of him. The Public Guardian's office, a division of the Department of Adult and Aging Services, is responsible for overseeing the financial matters of adults who are considered legally "incapacitated." Many of these adults, like John, have a chronic mental illness and are marginally functional as long as they stay on their medication. Under the Landerman-Petris-Short (LPS) Act of 1969, the court can appoint a temporary conservator for a mentally ill person who is unable to care for him- or herself.

The Public Guardian can also become the legal caretaker of elderly people with diseases like Alzheimer's who are unable to make decisions for themselves. This is called a probate conservatorship, and is usually permanent, unlike the LPS conservatorship, which ends as soon as the court is satisfied that the person can fend for him- or herself, which almost always happens within a year. The office, on Edgewater Drive near the Oakland Airport, is airy and serene, far removed from the chaos of our county's hospitals and the streets of our neighborhoods. Yet those who work here have to weave the ultimate safety net for those adults who are the most alone, the most vulnerable. In the hospital where I work, I often see patients who have been "found down": In other words, they collapsed on the street or in their homes, and that's about all we know about them. The ambulance report says "found down"; the emergency-room doctor writes "found down." While my first order of business as a doctor is to try to figure out what the patient's medical problem might be, I ask for a consultation with a social worker right away. The reason this person was "found down" rather than brought in by a relative is going to be as important in planning his or her care as the medical diagnosis.A certain percentage of these patients will wake up and return to their previous lives. The heroin addict who overdosed and refuses treatment and leaves the hospital as soon as he can walk, and the pregnant woman who fainted while shopping at Sears, are not going to end up wards of the state. On the other hand, the elderly gent who has become increasingly vague in the last few years, dependent on the charity of neighbors and avoiding the doctor, might have only broken his hip when he fell, but after a mental-status assessment he proves too confused to go home by himself. His closest relative is a grandnephew in Florida who has neither the desire nor the means to take him in. This man is a prime example of the sort of patient we would start on the probate-conservatorship track. A doctor has to fill out a long form, documenting this patient's memory loss, and then the court is to decide whether the patient is truly unable to make decisions for himself. If at all possible, the patient himself will appear before the judge.

The term "probate conservatorship" is left over from the days when only elderly people with property or other assets were accepted into the program. Elderly folks with money often have private probate conservators. When people do have savings, the court awards the county conservator, like the private conservator, a fee to cover the cost of the financial management. At present, the Public Guardian's office is handling about 660 LPS conservatorships and 440 probate conservatorships--far fewer than the estimated 6,000 private probate conservatorships in the county. Lately, the Public Guardian has been asked to take on more and more clients who have no assets. In these cases, we taxpayers are funding the safety net.The Department of Adult and Aging Services is also the home of Adult Protective Services (APS), an investigative arm of the agency. At my hospital, our social workers call in an APS officer anytime a patient complains of mistreatment or arrives with evidence of neglect, like deep pressure sores. For example, I recently cared for a 103-year-old woman who lived with her 94-year-old nephew. She was too weak to hoist herself out of bed, and so skinny that she had developed sores over every bony prominence below her waist: heels, hips, tailbone. She didn't see too well, and couldn't hear much, but there was nothing fuzzy about her thinking.A social worker at another hospital had already called APS to evaluate Auntie's living situation a few months before. They described a home littered with cat droppings, where Auntie lay unattended for hours at a time in her bed. Having promised his late wife that he would never let Auntie go to a nursing home, the nephew had reluctantly agreed to let a home health aide (whose salary was paid by the state) come and help for a few hours a day, but he had resisted an offer to increase the aide's hours. According to the aide, who had called the ambulance, the nephew was barely able to walk himself, yet he insisted that he could handle his aunt. Auntie wanted to return home to him, too, although the combination of malnutrition and bedsores was literally eating her body away.

This story did not have a happy ending. APS could make sure a social worker kept tabs on these two, urging them to accept all the help available, but no one pays for 24-hour home care for the indigent. Auntie agreed to a temporary stay at a hospital specializing in wound care, but if she goes back home, any of that healing will be undone. There is no legal way to pry Auntie out of her house without declaring her incompetent.

APS officers can do more to prevent "fiduciary" or financial abuse of the elderly. Robert Henderson, division director of APS, once told me a hair-raising story of a demented senior citizen who was hospitalized for six months because it was not safe to discharge him and send him home with his wife, who was also mentally confused. She refused to sign him into a nursing home and tried to block the petition for conservatorship that the social workers had filed.

Meanwhile, the wife was running up a credit-card debt. And unfortunately, she had taken a phone call from a con artist who offered to consolidate her debt under a second mortgage at an exorbitant rate. The swindler then posed as a conservator to get the husband to sign the documents. This pair would never have been able to make the payments, and would have lost their house, their primary asset, if the hospital social worker hadn't alerted APS, which moved quickly to obtain a court order to block the filing of the new mortgage.

The Hospital Consortium of Alameda County (a group representing all the hospitals) wishes that the conservator process could be speeded up. Its members are concerned about the number of patients in our county who stay on and on in hospitals because they will not agree to what seems the only reasonable discharge option. Typically, it takes 30-120 days to obtain a probate conservatorship in Alameda County. That's quick in doctor/lawyer/social worker time, but it makes for far too many of what we call "avoidable hospital days."While a more streamlined process sounds like a good idea, we have to be careful to protect an individual's civil liberties. Often as not, the conservatorship relationship is an adversarial one. No one wants to hear that they can't manage their affairs themselves, to admit that they are "incapacitated." If Uncle Harry, who has always been a stubborn cuss, now refuses help and uses trash as a barricade, isn't that his right?Ideally, we would be sufficiently connected to each other that it wouldn't take an APS investigation to discover that our neighbor was failing. But the American way means that we want to preserve our mobility and independence at all costs. No one can predict who will become a schizophrenic, but we will all age. Fifty percent of people over age 85 will develop Alzheimer's disease. By and large, the elderly who end up conserved don't have unusual problems or rare diseases. They just have less social support than they need to face the typical problems of aging.

As baby boomers age, they will swamp the system. And the same "village" that has been raising the children (or not) and watching over Big John (with mixed success) is going to be called upon to look out for a generation that hated growing up and is not going to like old age.

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