Navigating the Challenges of Conservators or Adult Guardians in Psychiatric Practice

An inpatient psychiatrist and her team are caught in a quandary. A hospitalized patient with chronic respiratory compromise is demanding to receive a COVID vaccination, but his conservator of person, also known as adult guardian in some states, is refusing to consent to the vaccination. Staff members suspect that the conservator’s refusal to approve the vaccination was driven by the conservator’s religious and spiritual beliefs. They also believe the patient’s best interest will be better served by getting the vaccination, given the patient’s underlying serious medical condition.

A different scenario is playing out in a sister hospital. A medically compromised patient admitted for psychiatric treatment is refusing the recommended COVID vaccination, but her conservator is insisting the psychiatrist should proceed with the injection, including holding or strapping down the patient to administer it. The psychiatrist is reluctant to do so over the patient’s objection but is worried about disregarding the request of the patient’s conservator.

Examples such as these—in which conserved patients’ requests are disapproved by their conservator—are common in psychiatric practice. Areas of conflicts include refusal to provide funds for cigarettes, certain food items, phones or computers, and alcoholic beverages and decisions regarding where to live. Often, the treating psychiatrist is caught in the middle.

A conservator is a person appointed by the probate court to oversee the financial and/or personal affairs of an adult who is determined by the court to be incapable of managing his or her finances or unable to care for himself or herself. Such patients may be unable to make decisions regarding their personal needs, including, but not limited to, the need for food, clothing, shelter, health care, and safety.

Ideally, probate court judges should state the decisions that conserved persons can or cannot make for themselves, as well as the decisions that are within the purview of conservators, as conserved individuals may retain the ability to make some decisions regarding their well-being. However, in my experience, many judges give blanket authority to the conservators, thereby robbing deserving patients of their decision-making autonomy. Granting conservators complete control over the affairs of another leaves conserved individuals vulnerable and at the mercy of the conservators. Such power is prone to abuse. Worse still, in most jurisdictions, the appointment is indefinite until challenged by the conserved individuals or others. Even voluntary conservatorship may be difficult to relinquish.

Although conservators are required to take patients’ wishes and values into consideration while making decisions for them, this is not always the case. Psychiatrists occasionally question the motives of conservators, especially when their decisions are not in the best interests of patients but rather appear to be self-serving.

Psychiatrists’ ethical obligations do not change when patients have a conservator. On the contrary, psychiatrists should be alert to evidence of patient maltreatment by conservators. Section 8 of APA’s “Principles of Medical Ethics” states, “A physician shall, while caring for a patient, regard responsibility to the patient as paramount.” Topic 3.1.1 of “APA Commentary on Ethics in Practice” recognizes that patients “sometimes struggle with symptoms that adversely affect their autonomous decision-making; the psychiatrist is responsible for rendering medical care in the patients’ best interest while respecting the patient’s goals and autonomy.”

To embody the key ethical considerations of respect for persons, fairness, and beneficence, the voice of conserved patients must always be given careful consideration and not quickly discarded on account of their status.

Psychiatrists’ obligation to protect patients’ best interests starts with the initial application for conservatorship, which must be made only after careful consideration as the consequences can be monumental. For already conserved patients, psychiatrists should examine the continued need for conservatorship at regular intervals and highlight tasks of which conserved patients are capable; patients’ autonomy should be restored as soon as possible.

When a psychiatrist determines that a conservator’s decisions are not in a patient’s best interests, the psychiatrist should advocate for the patient’s wishes with the conservator. If this fails, the psychiatrist should contact the court that appointed the conservator to petition for termination of the conservator.

In the examples described earlier, if negotiations with the conservator fail, the psychiatrist should present the case to the probate court to seek reversal of the conservator’s decision. However, if the court approves the conservator’s plan, the psychiatrist must comply with the court’s decision while continuing to support the patient through the unfortunate situations. The patient remains the focus of attention. ■

Charles C. Dike, M.D., M.P.H., is the immediate past chair of the APA Ethics Committee and former chair of the Ethics Committee of the American Academy of Psychiatry and the Law. He is also a professor of psychiatry; co-director of the Law and Psychiatry Division at the Yale University School of Medicine; and medical director in the Office of the Commissioner, Connecticut Department of Mental Health and Addiction Services.