Hospital Guardianship: A Quality Needs Assessment of “Unbefriended” Patients Who Lack Decisional Capacity

Emma Babb*, Andrew Matrick, Teresa Pollack, Lisa J. Rosenthal

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

7 Scopus citations


Background: The “unbefriended” patient does not demonstrate capacity to make their own medical decisions, does not have an advance directive, and lacks a surrogate decision maker. For these patients without a designated health care proxy, hospitals may need to petition for public guardianship, a notoriously arduous process with undefined impact on hospital resources. Objective: The objective of this study was to describe the characteristics, system needs, and financial impact of unrepresented inpatients in an academic, tertiary care, urban medical center. Methods: The Northwestern Memorial Hospital Quality and Patient Safety Committee approved a systematic needs assessment. Retrospective chart review was conducted for patients admitted from September 1, 2013 to August 31, 2019 for whom the hospital petitioned for a public guardian. Results: From fiscal years 2014 to 2019, 156 patients were petitioned for public guardianship. The number of cases rose sequentially from 8 in 2014 to 44 in 2019. The 2 most common conditions that impaired capacity were neurocognitive disorders (56.4%) and psychotic disorders (17.9%). The psychiatry consultation service consulted 71.2% of cases vs 71.1%. There were 2347 medically unnecessary hospital days related to the pursuit of guardianship, and the associated costs to the health system were estimated to be more than $5.8 million. Conclusions: The number of unbefriended patients who lacked decisional capacity necessitating public guardianship dramatically escalated over 5 years. These patients had high rates of homelessness and psychiatric illness, consistent with previous research. Further investigation is needed to understand and address the needs of this vulnerable population.

Original languageEnglish (US)
Pages (from-to)538-545
Number of pages8
JournalJournal of the Academy of Consultation-Liaison Psychiatry
Issue number5
StatePublished - Sep 1 2021


  • decision-making capacity
  • ethics
  • guardianship
  • health needs assessment
  • legal
  • unbefriended

ASJC Scopus subject areas

  • Psychiatry and Mental health
  • Clinical Psychology


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