Module 3 - Residential and Social Decisions

  Residential and Social Decisions

 A. Family Issues and Conflicts

  Case 3.1: Daughter impedes Mother’s care


 Ms. R. is a legally incompetent 95-year-old woman with a diagnosis of dementia. She has a 75-year-old daughter, Ms. D., with whom she has been living. Ms. D., a paranoid schizophrenic, doesn’t take the medication prescribed for her psychiatric illness and has been interfering with Ms. R.’s care. Ms. R.’s guardian is seriously concerned about the living situation and the effect it is having on her ward.

The guardian arranged for care management services (personal attendants) to ensure that medication was administered to Ms. R., that the house was clean and that Ms. R. was receiving the appropriate and necessary daily care. Ms. D., however, does not permit the attendants to enter the home.

As a result, Ms. R. is no longer receiving an appropriate level of care. Ms. D. selectively medicates her mother, and the living conditions in the house have become unsanitary. In addition, Ms. D. is alienating Ms. R. from the rest of the family and restricting visitation.

Ms. R. does not wish to be separated from her daughter.



Questions for Discussion
  1. Should the guardian consider seeking a separation of mother and daughter? Why or why not?
  2.  Should a guardian be sought for the daughter? If so, how should the two guardians communicate and collaborate to protect their respective wards?
  3.  What other information is required, if only, do you want before making a decision in this case?

B. Placement

  Case 3.2: Ward’s wishes vs. risk of injury

 The ward is a 22-year-old developmentally disabled female. She lived with her mother until 2 years ago when her mother died. The whereabouts of the ward’s father are unknown.

A professional guardian was appointed over the ward’s person and the right to determine residence was delegated to the guardian. After an evaluation of the home setting, after considering the available alternatives – residence with the ward’s willing 24-year-old sister and the sister’s 26-year-old boyfriend, or residence in a group home – and after consultation with the ward whose preference it is to reside with her sister, the guardian determined that the ward would reside with her sister.

The ward has been in that residence for the past two years, is doing well and is emotionally attached to her sister, her sister’s boyfriend and their new child (the ward’s niece). Recently, the sister’s boyfriend was arrested and charged with leaving the scene of an accident and driving under the influence of alcohol. The sister’s boyfriend occasionally provides transportation for the ward. Should the guardian consider changing the ward’s residence?



Questions for Discussion
  1. Does the sister’s boyfriend put the ward at risk? In what ways, and to what extent?
  2.  How should the guardian’s obligation to protect her ward be balanced against the ward’s desire to reside with family members?
  3.  Can the guardian seek to impose restrictions on family members that would minimize risk to the ward?


 Case 3.3: Conflict of interest in placement decision


Ward lived independently in his own apartment. He had a job, a dog and a bicycle that he rode frequently. He was well known and liked in the community. He had no family in the area, but had become active in his church.

His guardian decided that he wasn’t safe in the community and relocated the ward to a long-term care facility. The guardian, it develops, had a financial interest in that facility.

Older residents at the facility eventually reported the appearance of new residents with no apparent need for nursing care. It was subsequently alleged that this placement was part of a larger scheme to fill empty nursing home beds.


Mary Johnson, Getting states to implement the Supreme Court’s integration ruling means fighting for dollars that nursing home operators see as rightfully theirs – by law, Ragged Edge Online, May/June 2000, at [link no longer available].

Questions for Discussion
  1. This case clearly is about a conflict of interest. Identify at least three ways a guardian might be in a conflict of interest situation.
  2.  Suppose the ward really was in need of nursing care. What should a guardian-investor do in such a case?
  3.  Identify a larger strategy for dealing with such issues. Consider, for instance, whether guardians should have anyinvestments in businesses or industries related to ward placement.


 Case 3.4: Guardian as advocate


 The ward, Camilla, lived in a state-run group home where she received medically necessary 24-hour nursing and attendant care. Camilla has significant cognitive deficiencies. Additionally, she suffers from seizure disorder, often becomes frightened at night and screams often.

Under great pressure to serve those with more severe care needs than Camilla, the state-run group home is considering transferring Camilla to a community-based home, where the level of care, due to insufficient funding, was substantially less. For instance, the community-based home did not have access to the specialized bathing devise used to irrigate Camilla’s external lesions, nor was it equipped to provide 24-hour nursing and attendant care that she required.

The guardian threatened legal action, and was able to keep Camilla in the state-run group home.

Impact Stories, The Arc, at
 Questions for Discussion
  1.  How far should a guardian go to advocate for a ward’s needs? Under what circumstances should a guardian threaten legal action?
  2. What moral responsibility – if any – does society have to provide adequate care for wards?
  3. Which social institutions bear that responsibility?
  4. Should public funding be increased to support care of this vulnerable population?
  5. Should taxes be increased to support such care? Would you agree to pay higher taxes if the increased revenue were used to support the state’s wards? Why or why not?