Reply to Comment on: End-of-Life Decision Making and Treatment for Patients with Professional Guardians

We appreciate the interest in our work by LaRock and colleagues.¹ As we detail in our recent manuscript,² the terminology around guardianship is complex and varies by jurisdiction. We use the term guardian to refer to a guardian of person — an individual appointed by a judge to make decisions about the well-being of another, including health care decisions. We refer to a professional guardian when the court selects a stranger, rather than a family member, for this role. While there are limited data available about the work background of professional guardians,³ they are usually not individuals with experience or training in health care.

Guardianship is currently the default mechanism for identifying a legally authorized decision maker for a person with prolonged incapacity who is unrepresented, with no appropriate surrogate.⁴ We fully agree, however, that it would be useful to consider other models, either as alternatives to guardianship or adjuncts to it. LaRock and colleagues call attention to the important contributions that Board Certified Patient Advocates can make in the care of older adults. Other experts have suggested that persons with intact capacity, but no family member or friend to serve as a surrogate if their capacity became impaired, be able to appoint a health fiduciary — “a new type of professional certified to act as surrogate decision-maker for individuals who become unable to make decisions for themselves.”⁵ Voluntary guardianship programs exist in several parts of the country, and these programs often do include persons from the health professions.⁶ New York, Texas, and Iowa allow specialized committees to make decisions for some patients who do not have an appropriate surrogate.^{4, 7} All these approaches deserve further discussion and study.