The man was adamant. He did not, he insisted, have any family. But while cleaning out his apartment, Mary Kate Egan stumbled on paperwork that clearly showed he had been married and had children.
Egan, a case manager at Public Guardian Services, was starting to manage health care decisions for the man, who had been living alone but was no longer capable of handling his own affairs and was moving into a nursing home. After Egan found the paperwork and asked the man about his family, he had a change of heart; he confessed to Egan that he now wanted to reconnect with them and that he was alienated from them because of his earlier gambling problems.
“I finally reached a son who said he didn’t want any contact and hadn’t seen him since he was 13,” Egan said. “Obviously [the man] was operating as if they didn’t exist. But when he changed his mind and wanted contact with his family, they didn’t want it.”
The man’s case is one of 20 Egan juggles, part of an ambitious initiative aimed at addressing an urgent and growing problem in Massachusetts: legions of people who are unable to make medical decisions for themselves but have no family members or friends willing or able to step in.
Lawyers and advocates estimate there are at least 3,000 such “unbefriended” people — most are older adults, though some are younger with brain injuries, intellectual disabilities, or mental health problems in need of a guardian. Massachusetts has had no central agency to handle these cases, nor a registry to track them.
Enter Public Guardian Services. The nonprofit pilot program, launched in 2020 in collaboration with the state’s Probate and Family Court, is providing guardians to about 100 people and managing their care in Suffolk, Norfolk, and Plymouth counties. The goal is to improve care for unbefriended people, while saving money for MassHealth, the state’s Medicaid program, which often ends up paying to keep people in need of guardians in expensive places, such as hospitals, because there’s no one to sign off on their discharge and assume responsibility for their care.
“We are trying to show that we can improve the quality of life for people who have nobody,” said Wynn Gerhard, board chair of the nonprofit and a former senior attorney with Greater Boston Legal Services.
Another goal: providing a three-county model of what could be done cohesively on a statewide level, Gerhard said.
She said the organization has had some success stories, resettling people stuck in hospitals or living on the streets in community-based programs, nursing homes, and assisted living facilities, and even a few in their own apartments.
“Some people, who are able, we terminate guardianship to help them get back their life,” she said.
The state is also pursuing a project it hopes will provide a better handle on the burgeoning problem.
In October 2021, the Probate and Family Court was awarded a nearly $1 million federal grant to create a statewide Office of Adult Guardianship and Conservatorship Oversight.
Evelyn Patsos, the court’s deputy legal counsel and project director, said a top priority is to create a system that will reliably monitor what they believe are thousands of current guardianship cases that have been appointed by, or requested from, the courts.
“We have anywhere from 23,000 to 35,000 guardianship cases in Massachusetts, just on adults,” Patsos said. “That ranges because we are trying to see if any have passed away.”
Other goals of the new office include creating a formal oversight system to regularly monitor guardians and ensure they are operating responsibly and establishing a state ombudsman program for families or other state agencies that have problems or may want to refer a case to protective services if they feel a guardian is not acting in the best interests of a client.
“We are bringing more staff to assist in this because it’s a huge endeavor,” Patsos said.
Fueling the problem is that often people fail to complete a health care proxy form, a simple document that designates a representative to make health care decisions for a person if he or she is incapacitated. Many other states have laws that allow someone else, such as a spouse, friend, or other family member, to make medical decisions when a proxy is missing — a law that, Patsos said, could ease the flood of guardianship petitions if it were enacted in Massachusetts.
A December survey by the Massachusetts Health and Hospital Association of administrators at three dozen hospitals revealed more than 150 people languishing in their beds, some for as long as 195 days, waiting for a guardianship or related conservatorship (to handle a person’s finances) to be finalized or expanded.
Brandon Saunders, whose law firm handles most of the new guardianship petitions in Eastern Massachusetts — they filed about 850 just last year and most involved hospital patients — said they struggle to find guardians because even those appointed by a court generally do not get paid.
“Reliance on volunteers to handle the bulk of the need for independent guardians in this Commonwealth is neither sustainable nor fair,” he said.
Pending legislation in Massachusetts aims to address that concern. The proposal (SD.698/HD.1727) would allow “reasonable” state-funded compensation for medical care-related duties of guardianship by professionals and extended family members. (Extended family is defined as those who are not a spouse, parent, grandparent, child, grandchild or sibling of the person needing a guardian.)
Saunders said his office has heavily relied on the new Public Guardian Services nonprofit as well as on one particular volunteer who has handled roughly 160 cases for them since 2016.
That volunteer is Brian McLaughlin, a Boston health care attorney who specializes in guardianships. He said he does pro bono requests from Saunders’ firm because his college education inspired him to “do good and do well.”
“When you are a guardian or conservator, it’s like being dropped out of a space ship and you have to quickly assess somebody’s life,” McLaughlin said. “You don’t know the person from a hole in a wall and you have to quickly relate to them and figure out what their needs are.”
McLaughlin said the on-call nature of guardianship works well with his lifestyle: He is not married and has no children.
“There are times I need to be on the phone at two in the morning because hospitals need an answer now,” he said. “They can’t wait on a do-not-resuscitate order, or someone had a slip and fall, or they need a consent signed for a new medication.”
McLaughlin is witnessing a rising number of requests for guardianship cases for younger people who have become incapacitated through addiction to alcohol and drugs.
He said the pending legislation that would allow state compensation could be helpful. He worries there is a shrinking pool of people willing to take on the time-consuming nature of the work amid a rising tide of guardianship requests.
“If I had fewer cases,” McLaughlin said, “I could visit my clients more and give them the TLC they deserve.”