As guardianship policies are regulated at the state level, practices vary widely, and there is no centralized database of guardians or wards to allow systematic study of how guardianship may impact an individual's care or quality of life. Furthermore, the guardianship process takes place outside of the clinical realm and in the probate court system, leading to uncertainty surrounding the process for many clinicians. Several high‐profile cases have illustrated how guardianship may lead to exploitation and abuse. However, a guardian's power to engage in decision‐making on behalf of the incapacitated individual (ward) is usually all‐encompassing and a major threat to individual autonomy. Guardianship is meant to serve as a mechanism of protection for vulnerable individuals. Guardianship is one option for incapacitated patients who do not have a previously designated power of attorney or another viable decision‐maker. Persons with dementia or other disabilities that impair rational thinking may lose their ability to participate in medical decision‐making as the condition progresses, and often require a surrogate decision‐maker. Physicians can serve as important allies and advocates for patients with cognitive impairment at risk of incapacity, can help preserve their autonomy for as long as possible, and ensure appropriate protections are in place if the patient does lose their decision‐making ability. Laws and regulations for guardianships vary significantly between states. Data about guardians and wards is shockingly sparse, as there are no centralized databases. The ongoing need for guardianship should be periodically revisited and reassessed. Although a number of viable alternatives to guardianship exist, numerous systemic barriers may prevent these from being fully explored. Guardians are encouraged to use substituted decision‐making, taking into account the ward's previously expressed values and preferences. Assigned guardians may be known to the incapacitated individual (e.g., a family member or friend) or may be professional guardians with no prior relationship to the ward. These determinations may be used to support a Petition for the Appointment of a Guardian of a Legally Incapacitated Adult, the legal process of pursuing guardianship in probate court. Although capacity assessments are usually task‐specific, geriatricians and other specialists may be asked to comment on capacity more globally. To have the capacity for medical decision making, individuals must understand relevant information, appreciate their circumstances, demonstrate reasoning, and express a consistent choice free from coercion. Older adults with dementia are particularly susceptible to loss of independence and the ability to participate in medical decision making. Guardianship may pose an ethical dilemma for physicians, who must balance protecting vulnerable patients from potential safety concerns with respecting their autonomy.
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