The Burden of Guardianship: A Matched Cohort Study

Ricotta, Daniel N; Parris, James; Parris, Ritika S; Sontag, David N.; Mukamal, Kenneth J.

doi:10.12788/jhm.2946

Cited by 20 publications

(16 citation statements)

References 12 publications

(23 reference statements)

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“…Patients with barriers that may put them at risk for prolonged hospitalization can now be identified earlier, and more intensive case management can be deployed for the patient. 25,26…”

Section: Discussionmentioning

confidence: 99%

Hospitalized After Medical Readiness for Discharge: A Multidisciplinary Quality Improvement Initiative to Identify Discharge Barriers in General Medicine Patients

2019

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Reducing the length of hospitalization is a shared priority for patients, clinicians, and other health care stakeholders. However, patients can remain hospitalized after being “medically ready” for discharge, accumulating delayed discharge bed days (DDBDs). As part of a quality improvement initiative, the authors developed a method to measure DDBD and define discrete barriers to discharge identified by inpatient clinicians. Patients with delayed discharge had a higher rate of in-hospital complications compared to those who were discharged routinely. To identify modifiable barriers among patients with delayed discharges, 2 patient subgroups were defined: prolonged hospitalization (>19 DDBDs, top quintile accumulated) and extended hospitalization (≤19 DDBDs). Patients with prolonged hospitalization were more likely than those with extended hospitalization to have financial ( P < .001) or behavioral ( P < .001) barriers, homelessness ( P < .05), and impairment of decision-making capacity ( P < .01). Understanding the characteristics and discharge barriers of patients who are hospitalized despite medical readiness may increase appropriateness of inpatient resources.

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“…Patients with barriers that may put them at risk for prolonged hospitalization can now be identified earlier, and more intensive case management can be deployed for the patient. 25,26…”

Section: Discussionmentioning

confidence: 99%

Hospitalized After Medical Readiness for Discharge: A Multidisciplinary Quality Improvement Initiative to Identify Discharge Barriers in General Medicine Patients

2019

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“…A one-year matched retrospective cohort study in one hospital compared the length of stay for patients for whom the hospital had initiated guardianship procedures because the patient had impaired decision-making and no designated surrogate decision-maker. This study compared patients for whom the hospital had initiated a petition to the court to appoint a guardian as surrogate decision-maker (e.g., volunteer, public, family member) compared to patients that did not have a guardian appointment (Ricotta, Parris, Parris, Sontag, & Mukamal, 2018). The guardianship process resulted in prolonged hospital stays (twenty-nine days compared to eighteen days for controls) and one in six had a hospital-associated complication upon discharge.…”

Section: Research On Public Guardianshipmentioning

confidence: 99%

Developing Age‐friendly Cities: Policy Opportunities and Challenges

Phillipson¹,

Buffel²

2020

Journal of Elder Policy

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This journal was initiated in 2019 during a period of relative calm and stability in the US. Our goal as a journal is to showcase cutting-edge scholarship in the field of aging and the social sciences that offers guidelines for practice and policy benefiting and protecting older adults. In a timely paper, expressions and consequences of ageism are addressed by Ayalon. Her essay focuses on ageism toward older adults at the macro-institutional level in policies or politics, at the meso level of interpersonal relations, and at the micro, intrapersonal level. She skillfully uses several contexts to demonstrate how ageism is manifested within policies, healthcare systems, workforces, and our ageist attitudes toward ourselves. Ayalon's article concludes with creative ways to combat such ageism.

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“…In addition, because there is no one to authorize discharge, the unrepresented often have prolonged hospital stays. ICU stays for unrepresented patients are often twice the duration of stays for other patients (9,10).…”

Section: Introductionmentioning

confidence: 99%

“…For these patients, there is no one with whom the clinician can engage in shared decision-making, which is recommended for important, value-laden decisions in ICUs (7). Available evidence shows that the absence of a decision-maker causes patients to face significant risks of being overtreated, undertreated, or otherwise treated inconsistently with their preferences and values (8)(9)(10).…”

mentioning

confidence: 99%

Making Medical Treatment Decisions for Unrepresented Patients in the ICU. An Official American Thoracic Society/American Geriatrics Society Policy Statement

Pope¹,

Bennett²,

Carson³

et al. 2020

Am J Respir Crit Care Med

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Background and Rationale: ICU clinicians regularly care for patients who lack capacity, an applicable advance directive, and an available surrogate decision-maker. Although there is no consensus on terminology, we refer to these patients as "unrepresented." There is considerable controversy about how to make treatment decisions for these patients, and there is significant variability in both law and clinical practice. Purpose and Objectives: This multisociety statement provides clinicians and hospital administrators with recommendations for decision-making on behalf of unrepresented patients in the critical care setting. Methods: An interprofessional, multidisciplinary expert committee developed this policy statement by using an iterative consensus process with a diverse working group representing critical care medicine, palliative care, pediatric medicine, nursing, social work, gerontology, geriatrics, patient advocacy, bioethics, philosophy, elder law, and health law. Main Results: The committee designed its policy recommendations to promote five ethical goals: 1) to protect highly vulnerable patients, 2) to demonstrate respect for persons, 3) to provide appropriate medical care, 4) to safeguard against unacceptable discrimination, and 5) to avoid undue influence of competing obligations and conflicting interests. These recommendations also are intended to strike an appropriate balance between excessive and insufficient procedural safeguards. The committee makes the following recommendations: 1) institutions should offer advance care planning to prevent patients at high risk for becoming unrepresented from meeting this definition; 2) institutions should implement strategies to determine whether seemingly unrepresented patients are actually unrepresented, including careful capacity assessments and diligent searches for potential surrogates; 3) institutions should manage decision-making for unrepresented patients using input from a diverse interprofessional, multidisciplinary committee rather than ad hoc by treating clinicians; 4) institutions should use all available information on the patient's preferences and values to guide treatment decisions; 5) institutions should manage decision-making for unrepresented patients using a fair process that comports with procedural due process; 6) institutions should employ this fair process even when state law authorizes procedures with less oversight. Conclusions: This multisociety statement provides guidance for clinicians and hospital administrators on medical decision-making for unrepresented patients in the critical care setting.

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The Burden of Guardianship: A Matched Cohort Study

Abstract: In this single-center cohort study, the guardianship process was associated with prolonged hospital stay and higher total hospital charges even when compared with matched controls. Furthermore, one in six patients suffered from a hospital-associated complication after medical clearance.

Cited by 20 publications

References 12 publications

Hospitalized After Medical Readiness for Discharge: A Multidisciplinary Quality Improvement Initiative to Identify Discharge Barriers in General Medicine Patients

Hospitalized After Medical Readiness for Discharge: A Multidisciplinary Quality Improvement Initiative to Identify Discharge Barriers in General Medicine Patients

Developing Age‐friendly Cities: Policy Opportunities and Challenges

Making Medical Treatment Decisions for Unrepresented Patients in the ICU. An Official American Thoracic Society/American Geriatrics Society Policy Statement

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