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

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.