The Legal and Ethical Aspects of Incapacity

Presented By:

www.ashmorelaw.com3636 Maple AvenueDallas, Texas 75219

214.559.7202 (phone)214.520.1550 (fax)

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Interesting statistics in Dallas County:◦ In 2009 - 6,077 Mental Illness cases were filed◦ In 2010 - 7,662 Mental Illness cases were filed◦ In 2011 – 8,091 Mental Illness cases were

filed

◦ In 2010 - 288 Guardianship cases were filed◦ In 2011 - 354 Guardianship cases were filed

There is also an increase in the elderly population:

◦ According to the 2010 census, 13% of the US population is over the age of 65.

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Think about the following scenario that goes something like this…

Son brings patient in because she has become more and more confused. She is his 72 year old mother. Her husband died over 10 years ago; however, she has started talking like he is still alive. She is beginning to have conversations with her deceased husband, as well as her deceased parents.

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You may be thinking she is showing signs of Dementia or Alzheimer’s.

So what’s the problem?

Medically… that may be where it ends, but you need to be aware of the legal issues when you hear the rest of the story…

Daughter, who has been estranged from her mother, is starting to come back into her life with her new “friend.” Daughter has taken Mom to the bank a couple of times and is staying at the house with her friend. You have a family meeting explaining Mom’s incapacity and her inability to make her own decisions. Son and Daughter need to work together to handle Mom’s affairs. 4

Unfortunately in the legal world it doesn’t end there.

Son now calls us… After the family meeting, Daughter took Mom to the bank. Mom added Daughter to all of her bank accounts. Not only that, Daughter took Mom to an attorney and Mom signed a new power of attorney naming Daughter. To make matters even worse, Mom deeded the house over to Daughter.

The first thing we discuss is the possibility of a Guardianship….

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What is a Guardianship?

Texas Probate Code § 602, Policy, Purpose of Guardianship.

A court may appoint a guardian with full authority over an incapacitated person or may grant a guardian limited authority over an incapacitated person as indicated by the incapacitated person's actual mental or physical limitations and only as necessary to promote and protect the well-being of the person. If the person is not a minor, the court may not use age as the sole factor in determining whether to appoint a guardian for the person. In creating a guardianship that gives a guardian limited power or authority over an incapacitated person, the court shall design the guardianship to encourage the development or maintenance of maximum self-reliance and independence in the incapacitated person.

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From the above scenario, even though you, as the doctor, told the family Mom did not have capacity to take care of her affairs, legally, there was nothing to stop Daughter from taking Mom to the bank or having her sign the legal documents.

A doctor may state that an individual is incapacitated; however, only a Probate Court can legally declare someone over the age of 18 incapacitated.

Without this declaration from the Probate Court, that individual has the same rights as you and I. They have the right to enter into contracts, sign legal documents, vote, marry, drive, etc.

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Incapacity has many definitions. One definition is “the inability to understand information presented, appreciate the consequences of acting – or not acting on that information, and to make a choice.”

An individual may be declared medically incapacitated, but that has no legal effect. Until there is a finding of legal incapacity, that individual maintains all of their civil rights and enjoys all of the same privileges of a fully capacitated individual.

In other words, without a finding of legal incapacity in the above scenario, Mom had the right to change her bank accounts, deed her house to Daughter and sign a new Power of Attorney.

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Texas Probate Code §§ 3(p) and 601(14) gives us the legal definition of incapacity.

"Incapacitated person" means:

(A) a minor;

(B) an adult individual who, because of a physical or mental condition, is substantially unable to provide food, clothing, or shelter for himself or herself, to care for the individual's own physical health, or to manage the individual's own financial affairs; or

(C) a person who must have a guardian appointed to receive funds due the person from any governmental source.

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Now that we have defined legal incapacity, next we have to determine whether the medically incapacitated individual requires a guardianship.

We must also determine whether there is a need for a Guardian of the Person, Guardian of the Estate, or both.

When a Court finds an individual to be legally incapacitated, they must also find whether that legal incapacity exists as it relates to their person, or if it also encompasses their estate.

What exactly does this mean?

Texas Probate Code §767 discusses the Powers and

Duties of Guardians of the Person.

(a) The guardian of the person is entitled to take charge of the person of the ward, and the duties of the guardian correspond with the rights of the guardian.  A guardian of the person has:

(1)  the right to have physical possession of the ward and to establish the ward's legal domicile;

(2)  the duty to provide care, supervision, and protection for the ward; (3)  the duty to provide the ward with clothing, food, medical care, and shelter; (4)  the power to consent to medical, psychiatric, and surgical treatment other

than the in-patient psychiatric commitment of the ward; and (5)  on application to and order of the court, the power to establish a trust in

accordance with 42 U.S.C. Section 1396p(d)(4)(B), as amended, and direct that the income of the ward as defined by that section be paid directly to the trust, solely for the purpose of the ward's eligibility for medical assistance under Chapter 32, Human Resources Code.

(b)  Notwithstanding Subsection (a)(4) of this section, a guardian of the person of a ward has the power to personally transport the ward or to direct the ward's transport by emergency medical services or other means to an inpatient mental health facility for a preliminary examination in accordance with Subchapters A and C, Chapter 573, Health and Safety Code.

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Texas Probate Code § 768 discusses the General Powers and Duties of Guardian of the Estate.

The guardian of the estate of a ward is entitled to the possession and management of all property belonging to the ward, to collect all debts, rentals, or claims that are due to the ward, to enforce all obligations in favor of the ward, and to bring and defend suits by or against the ward; but, in the management of the estate, the guardian is governed by the provisions of this chapter. It is the duty of the guardian of the estate to take care of and manage the estate as a prudent person would manage the person's own property, except as otherwise provided by this chapter. The guardian of the estate shall account for all rents, profits, and revenues that the estate would have produced by such prudent management.

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Texas Probate Code § 770 discusses the Guardian’s responsibility for the Care of Ward; Commitment

(a) The guardian of an adult may expend funds of the guardianship as provided by court order to care for and maintain the incapacitated person. The guardian may apply for residential care and services provided by a public or private facility on behalf of an incapacitated person who has decision-making ability if the person agrees to be placed in the facility. The guardian shall report the condition of the person to the court at regular intervals at least annually, unless the court orders more frequent reports. If the person is receiving residential care in a public or private residential care facility, the guardian shall include in any report to the court a statement as to the necessity for continued care in the facility.

(b) Except as provided by Subsection (c) or (d) of this section, a guardian may not voluntarily admit an incapacitated person to a public or private in-patient psychiatric facility or to a residential facility operated by the Texas Department of Mental Health and Mental Retardation for care and treatment. If care and treatment in a psychiatric or a residential facility are necessary, the person or the person's guardian may:

(1) apply for services under Section 593.027 or 593.028, Health and Safety Code;

(2) apply to a court to commit the person under Subtitle D, Title 7, Health and Safety Code (Persons with Mental Retardation Act), Subtitle C, Title 7, Health and Safety Code (Texas Mental Health Code),or Chapter 462, Health and Safety Code; or

(3) transport the ward to an inpatient mental health facility for a preliminary examination in accordance with Subchapters A and C, Chapter 573, Health and Safety Code.

(c) A guardian of a person younger than 18 years of age may voluntarily admit an incapacitated person to a public or private inpatient psychiatric facility for care and treatment.

(d) A guardian of a person may voluntarily admit an incapacitated person to a residential care facility for emergency care or respite care under Section 593.027 or 593.028, Health and Safety Code.

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As an attorney, the following are the steps we would take if presented with the Scenario we discussed earlier:

Son contacts our law firm because he does not know what to do.

The first determination we need to make is whether we need a Temporary Guardian or Permanent Guardian.

In order to find whether a Temporary Guardianship is needed we must first ask ourselves if an immediate necessity exists. That is, whether harm could come to mom’s person or her estate if a Guardian is not appointed immediately.

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Daughter has already taken Mom to the bank and is now on the bank accounts.Furthermore, Daughter had Mom sign a new Power of Attorney.Mom deeded the house over to Daughter.

Given this scenario, there is an immediate necessity. We file an Application for Temporary Guardian. The Court will hear this matter within ten (10) days. It is in place for 60 days, at which time it expires unless we show the Court we need a Permanent Guardianship.

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The next question we must ask ourselves is whether we need a Guardian of the Person, Guardian of the Estate or both.

In this scenario, we need Guardian of the Person and Estate to make sure Mom is protected as well as her assets.

We are ready to convert Temporary Guardianship to a Permanent Guardianship. We are ready to file our Application for Appointment of Guardian of the Person and Estate.

BUT WAIT…

We are missing a very important document that will be the basis and foundation of our Application…

The “Doctor’s Letter”

The requirements of this Doctor’s Letter is listed under Texas Probate Code § 687, Examinations and Reports:

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(a) Except as provided by Subsection (c) of this section, the court may not grant an application to create a guardianship for an incapacitated person, other than a minor or person for whom it is necessary to have a guardian appointed only to receive funds from a governmental source, unless the applicant presents to the court a written letter or certificate from a physician licensed in this state that is dated not earlier than the 120th day before the date of the filing of the application and based on an examination the physician performed not earlier than the 120th day before the date of the filing of the application. The letter or certificate must:

(1)  describe the nature, degree, and severity of incapacity, including functional deficits, if any, regarding the proposed ward's ability to:

(A)  handle business and managerial matters; (B)  manage financial matters; (C)  operate a motor vehicle; (D)  make personal decisions regarding residence, voting, and marriage; and (E)  consent to medical, dental, psychological, or psychiatric treatment; (2)  provide an evaluation of the proposed ward's physical condition and mental

function and summarize the proposed ward's medical history if reasonably available;

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(3)  state how or in what manner the proposed ward's ability to make or communicate responsible decisions concerning himself or herself is affected by the person's physical or mental health, including the proposed ward's ability to:

(A)  understand or communicate; (B)  recognize familiar objects and individuals; (C)  perform simple calculations; (D)  reason logically; and (E)  administer to daily life activities; (4)  state whether any current medication affects the demeanor of the

proposed ward or the proposed ward's ability to participate fully in a court proceeding;

(5)  describe the precise physical and mental conditions underlying a diagnosis of a mental disability, and state whether the proposed ward would benefit from supports and services that would allow the individual to live in the least restrictive setting;

(6)  in providing a description under Subdivision (1) of this subsection regarding the proposed ward's ability to operate a motor vehicle and make personal decisions regarding voting, state whether in the physician's opinion the proposed ward:

(A)  has the mental capacity to vote in a public election; and (B)  has the ability to safely operate a motor vehicle; and (7)  include any other information required by the court.

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To simplify this, the Dallas County Probate Courts have created a form Doctor’s Letter that meets all of the above requirements.

After reviewing the original completed Doctor’s Letter the Application is prepared attaching the Letter as an exhibit.

The only involvement at this point for the doctor is completing this Doctor’s Letter.

But wait…

The Court now appoints an Attorney Ad Litem. The responsibility of this Attorney Ad Litem is to advocate for the individual, (“Proposed Ward”).

If the patient wants to contest the Application, now as the doctor, you may have more of an active role in the legal process. Keep in mind the individual or any interested person may contest these proceedings.

If the contest is centered around whether a Guardianship is necessary or the degree of incapacity is being questioned, then the doctor becomes an integral part of the proceedings.

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b)  If the court determines it is necessary, the court may appoint the necessary physicians to examine the proposed ward.  The court must make its determination with respect to the necessity for a physician's examination of the proposed ward at a hearing held for that purpose.  Not later than the fourth day before the date of the hearing, the applicant shall give to the proposed ward and the proposed ward's attorney ad litem written notice specifying the purpose and the date and time of the hearing.  A physician who examines the proposed ward, other than a physician or psychologist who examines the proposed ward under Subsection (c)(2) of this section, shall make available to an attorney ad litem appointed to represent the proposed ward, for inspection, a written letter or certificate from the physician that complies with the requirements of Subsection (a) of this section.

(c)  If the basis of the proposed ward's alleged incapacity is mental retardation, the court may not grant an application to create a guardianship for the proposed ward unless the applicant presents to the court a written letter or certificate that:

(1) complies with Subsection (a) of this section; or (2) shows that: (A) not earlier than 24 months before the date of the hearing, the proposed

ward has been examined by a physician or psychologist licensed in this state or certified by the Department of Aging and Disability Services to perform the examination, in accordance with rules of the executive commissioner of the Health and Human Services Commission governing examinations of that kind; and

(B) the physician's or psychologist's written findings and recommendations to the court include a statement as to whether the physician or psychologist has made a determination of mental retardation in accordance with Section 593.005, Health and Safety Code.

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Depending on the facts surrounding the contest, the Court may appoint a Guardian Ad Litem. The role of the Guardian Ad Litem is to act in the best interest of the Proposed Ward.

NOTE: There is a difference between the Attorney Ad Litem and the Guardian Ad Litem.

HOWEVER, both are entitled to receive any and all medical records or reports from any doctor’s office or medical facility, hospital, etc.

So what exactly is the doctor or mental health provider’s involvement now?

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The involvement may be as little as having a phone conversation with the attorneys and ad litems,

OR

As involved as giving a deposition or testimony in open court.

Remember, when determining (1) whether an individual is legally incapacitated, and/or (2) the degree of the legal incapacity, the Court is looking to that Doctor’s Letter or even the doctor’s testimony in open court.

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So far we have answered the question “what is a Guardianship?”

We have defined Guardianship as well as legal incapacity.

Now we know that only a Probate Court can legally declare someone over the age of 18 incapacitated.

We also know that even though an individual may be found to be medically incapacitated, they may not be legally incapacitated.

So what’s next? 25

Now we will discuss those individuals who are incapacitated because of a mental illness and the Involuntary Commitment Process.

Later, we will discuss how a Guardianship can help facilitate the Involuntary Commitment process and vice versa, and how they can go hand in hand.

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The Health and Safety Code gives us the applicable law as it relates to the mentally ill, voluntary inpatient mental health services, emergency detention, court-ordered mental health services, etc.

For purposes of this presentation, we will discuss the involuntary commitment process.

Health and Safety Code § 573.001 and § 573.011 discuss the requirements for Apprehension by a Peace Officer Without a Warrant and the requirements for an Application for Emergency Detention, respectively.

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§573.001. Peace Officers Application for Detention states:

(a) A peace officer shall immediately file an application for detention after transporting a person to a facility under Section 573.001.

(b)  The application for detention must contain: (1)  a statement that the officer has reason to believe and does believe that

the person evidences mental illness; (2)  a statement that the officer has reason to believe and does believe that

the person evidences a substantial risk of serious harm to himself or others; (3)  a specific description of the risk of harm; (4)  a statement that the officer has reason to believe and does believe that

the risk of harm is imminent unless the person is immediately restrained; (5)  a statement that the officer's beliefs are derived from specific recent

behavior, overt acts, attempts, or threats that were observed by or reliably reported to the officer;

(6)  a detailed description of the specific behavior, acts, attempts, or threats; and

(7)  the name and relationship to the apprehended person of any person who reported or observed the behavior, acts, attempts, or threats.

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§573.011. Application for Emergency Detention states:(a) An adult may file a written application for the emergency detention of another person.(b)  The application must state:(1)  that the applicant has reason to believe and does believe that the person evidences mental illness;(2)  that the applicant has reason to believe and does believe that the person evidences a substantial risk of serious harm to himself or others;(3)  a specific description of the risk of harm;(4)  that the applicant has reason to believe and does believe that the risk of harm is imminent unless the person is immediately restrained;(5)  that the applicant's beliefs are derived from specific recent behavior, overt acts, attempts, or threats;(6)  a detailed description of the specific behavior, acts, attempts, or threats; and(7)  a detailed description of the applicant's relationship to the person whose detention is sought.(c)  The application may be accompanied by any relevant information.

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Once this process begins and an individual is transported to a psychiatric facility, the MI Court, per the Health and Safety Code, appoints an attorney to represent the patient.

The attorney has the authority and responsibility to visit with the patient and obtain access to the medical and psychiatric records.

At the time of appointment, the attorney is not given the patient code, therefore although the attorney does not have the patient code, they are still to be given all of the information and the ability to privately meet with the patient.

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The attorney’s role is to advocate for the patient. What that means is if the patient expresses they want to leave the hospital, the attorney must argue for that.

What is the doctor’s role in this process?

The doctor must complete a Certificate under Health and Safety Code section 574.011, Certificate of Medical Examination for Mental Illness, which states:

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(a) A certificate of medical examination for mental illness must be sworn to, dated, and signed by the examining physician. The certificate must include:

(1)  the name and address of the examining physician; (2)  the name and address of the person examined; (3)  the date and place of the examination; (4)  a brief diagnosis of the examined person's physical and mental condition; (5)  the period, if any, during which the examined person has been under the care of the

examining physician; (6)  an accurate description of the mental health treatment, if any, given by or administered

under the direction of the examining physician; and (7)  the examining physician's opinion that: (A)  the examined person is mentally ill; and (B)  as a result of that illness the examined person is likely to cause serious harm to himself or

to others or is: (i)  suffering severe and abnormal mental, emotional, or physical distress; (ii)  experiencing substantial mental or physical deterioration of his ability to function

independently, which is exhibited by the proposed patient's inability, except for reasons of indigence, to provide for the proposed patient's basic needs, including food, clothing, health, or safety; and

(iii)  not able to make a rational and informed decision as to whether to submit to treatment. (b)  The examining physician must specify in the certificate which criterion listed in Subsection

(a)(7)(B) forms the basis for the physician's opinion. (c)  If the certificate is offered in support of an application for extended mental health

services, the certificate must also include the examining physician's opinion that the examined person's condition is expected to continue for more than 90 days.

(d)  If the certificate is offered in support of a motion for a protective custody order, the certificate must also include the examining physician's opinion that the examined person presents a substantial risk of serious harm to himself or others if not immediately restrained. The harm may be demonstrated by the examined person's behavior or by evidence of severe emotional distress and deterioration in the examined person's mental condition to the extent that the examined person cannot remain at liberty.

(e)  The certificate must include the detailed reason for each of the examining physician's opinions under this section.

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This Certificate, as with the Doctor’s Letter in the Guardianship process, is the basis and foundation at the patient’s commitment hearing.

The doctor must take the stand, as the State’s witness, to testify why the patient should be committed to a psychiatric facility for inpatient treatment.

The Attorney for the patient will have a right to cross examine the doctor, in addition the patient will have the right to testify on their own behalf.

If the Judge finds by clear and convincing evidence the criteria as set out in Health and Safety Code section 574.034, they will sign the Order for Temporary Mental Health Services. 33

We get a call from Father with the following situation:

◦ Son is 24 years old◦ Has not slept in days◦ Stays up all night wandering around◦ Has had psychiatric hospitalizations in the past◦ Last one was 2 years ago◦ Has been seeing psychiatrist but is now refusing to go◦ Had been taking his psychiatric medications, but

stopped 2 months ago◦ Has not eaten in last couple of days◦ Increasingly agitated◦ Throwing and breaking items◦ Threatening Father◦ Son is refusing to voluntarily go to the psychiatric

facility◦ According to Son, he does not have a mental illness,

but actually Father is the one with the problem.

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What does Father do?

We can agree Son is a danger to himself and others, which has been evidenced by a recent overt act.

Father has TWO options…

OPTION 1:

Call 911 and under Health and Safety Code Section 573.001, Son will be apprehended by the police without a warrant and taken to a psychiatric facility that has an ER.

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OPTION 2:

Father can fill out an Application for an MIW or “Mental Illness Warrant.” under Health and Safety Code Section 573.011 Once the Order is signed by the Judge the Warrant is taken to the Sheriff’s department to be executed within 10 days. Once executed, Son will be picked up and taken to a psychiatric facility that has an ER.

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Once Son is evaluated in the ER, the doctor will determine whether he meets the criteria to be admitted to the psychiatric facility.

Once admitted, the Involuntary Commitment Process will begin.

As you can see, under the Guardianship Process or the Involuntary Commitment Process the doctor plays a very integral and important role in protecting an individual from being exploited, whether by a family member or friend, or protecting an individual from harming themselves or others.

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Many times we tell clients if their loved one had cancer, the involuntary commitment process is like applying a Band-Aid to the cancer, whereas the guardianship process is like applying chemotherapy.

Within the last 10-15 years, the Texas legislature enacted statutes that allowed guardians to take more of an active role with the involuntary commitment process.

Under Texas Probate Code § 767(b), Power and Duties of Guardians of the Person,

“…a guardian has the power to personally transport the ward or to direct the ward’s transport by emergency medical services or other means to an inpatient mental health facility for a preliminary examination…”

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Under Texas Probate Code § 770(b)(c), Care of Ward; Commitment,

◦ (b) Except as provided by Subsection (c) or (d) of this section, a guardian may not voluntarily admit an incapacitated person to a public or private in-patient psychiatric facility or to a residential facility operated by the Texas Department of Mental Health and Mental Retardation for care and treatment. If care and treatment in a psychiatric or a residential facility are necessary, the person or the person's guardian may:

◦ (1) apply for services under Section 593.027 or 593.028, Health and Safety Code;

◦ (2) apply to a court to commit the person under Subtitle D, Title 7, Health and Safety Code (Persons with Mental Retardation Act), Subtitle C, Title 7, Health and Safety Code (Texas Mental Health Code),or Chapter 462, Health and Safety Code; or

◦ (3) transport the ward to an inpatient mental health facility for a preliminary examination in accordance with Subchapters A and C, Chapter 573, Health and Safety Code.

◦ (c) A guardian of a person younger than 18 years of age may voluntarily admit an incapacitated person to a public or private inpatient psychiatric facility for care and treatment.

◦ (d) A guardian of a person may voluntarily admit an incapacitated person to a residential care facility for emergency care or respite care under Section 593.027 or 593.028, Health and Safety Code.

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Furthermore, under § 770A, Care of Ward; Commitment,

(a) In this section, " psychoactive medication" has the meaning assigned by Section 574.101, Health and Safety Code.

(b) If a person under a protective custody order as provided by Subchapter B, Chapter 574, Health and Safety Code, is a ward who is not a minor, the guardian of the person of the ward may consent to the administration of psychoactive medication as prescribed by the ward's treating physician regardless of the ward's expressed preferences regarding treatment with psychoactive medication.

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Depending on the situation, in reality, there will be instances where it will be more beneficial to get the individual to the psychiatric facility to begin the involuntary commitment process so that our client knows their loved one is in a safe environment and being evaluated by a doctor.

In this instance, we ask for the cooperation of the doctor in completing the Doctor’s Letter so that we may institute the guardianship proceedings that way a Guardian is in place when the patient leaves the hospital.

With everyone’s cooperation, we hope to ensure the safety of the patient when they are released from the hospital.

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In the other instance, if we see an individual is being exploited by a family member, caretaker or friend, we will begin the Guardianship process.

Once in place, if the ward is in need of psychiatric help, the Guardian can then transport the ward to the psychiatric facility for a preliminary evaluation and possibly the beginning of the involuntary commitment process if the Ward meets the criteria.

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As stated earlier in the presentation, one of the most important reasons it may become necessary to couple a guardianship with the involuntary commitment process is for the Guardian to have the authority, even without the consent of the patient, to speak with the doctor and care managers.

It is with this communication that the Guardian can ensure the patient has the support system in place after discharge from the hospital.

It also ensures that the doctor and care managers have the necessary information and history to act in the best interest of the patient in understanding the patient’s illness and medications and what works and what doesn’t.

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We have discussed the Guardianship Process.

We have discussed the Involuntary Commitment Process.

We have discussed how the Guardianship Process and Involuntary Commitment Process can work together.

Now we will discuss the alternatives to the Guardianship Process.

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Alternatives to GuardianshipManaging your Affairs During

Disability/Incapacity Estate Planning does not

only encompass death-time planning, but also disability or incapacity during life.

It is important to have the following documents:

Durable Power of Attorney

Medical Power of Attorney

Directive to Physicians HIPAA Authorization Declaration of Guardian

Directive to Physicians•Declares your wishes with respect to life-prolonging treatments and procedures.

Durable Power of Attorney•Names individuals to make your business and financial decisions for you in the event of incapacity or disability.

Medical Power of Attorney•Names individuals to make your medical and health care decisions for you in the event of incapacity or disability.

HIPAA Authorization•Permits you to name individuals to have access to your medical information and records.

Declaration of Guardian•Names individuals who will be the guardian of your person and your estate in the event of incapacity.

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Presentation written by:Lori Ashmore Peters

The Ashmore Law Firm3636 Maple AvenueDallas, Texas 75219

214-559-7202www.ashmorelaw.com

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“This material is a publication of The Ashmore Law Firm, P.C. and should not be construed as offering legal

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