GUARDIANS, WARDS, AND SERVICE PROVIDERS How to Create an Effective Working Relationship Susan McGuigan Patrick McGuigan Eric Jonsgaard, First Fiduciary Corp.

HOW WE GOT HERE

EFFECTS OF BRAIN INJURY Physical: Ambulation Manual Dexterity Fatigue Visual Impairment Difficulty Swallowing Headaches Behavioral & Emotional: Anger Management Depression Anxiety Insight into Condition Cognitive: Memory Attention Planning and Organization Decision Making and Problem Solving Processing Speed Judgment Impulsivity

EFFECTS ON DECISION MAKING Taking a long time to make a decision Making inappropriate and/or potentially harmful decisions Responding impulsively to situations Having a hard time recognizing problems Slow to think of alternate solutions to problems Tendency to be “concrete” in terms of problem solving, that is, difficulty making inferences Taking things literally Difficulty reasoning Ineffective problem solving Acting without thinking about potential consequences (e.g., crossing the street without checking traffic)

ATTENTION PROBLEMS Short attention span, sometimes only minutes in duration Easily distracted Difficulty in attending to one or more things at a time Inability to shift attention from one task or person to the next Difficulty completing tasks

MEMORY ISSUES Difficulty remembering information from day to day about people, conversations, places, events, appointments, dates, and telephone numbers Keys, wallet, etc. are frequently lost or misplaced Repeating questions or the same story over and over again Difficulty learning new information and using it in everyday life Making up convincing stories to fill memory gaps

DIFFICULTIES WITH PLANNING AND ORGANIZATION Problems organizing time to get things done Problems understanding which tools are needed to complete a task and getting them together Problems breaking down complex tasks into smaller steps Having a hard time getting ready for work, school, and appointments Being late for appointments and work or school Having a hard time starting a task Problems making plans and completing them Problems setting goals Trouble prioritizing

LACK OF INSIGHT INTO DEFICITS Underestimating the problem areas related to TBI Not understanding why rehabilitation therapies are needed Not following the recommendations of the health care team (i.e., driving restrictions, no alcohol) Unrealistic expectations about future plans or abilities

TECHNIQUES FOR WORKING WITH INDIVIDUAL WITH A BRAIN INJURY Avoid having the individual with a brain injury make decisions when tired, hungry, or under stress. Help the individual to weigh options and consequences of a decision. Give the individual time to make a decision. Be patient and talk him or her through the possible options. Limit the number of possible choices. Two or three choices is best. Too many are often overwhelming and can increase indecisiveness. Avoid making last minute decisions. Brainstorm possible solutions and evaluate the alternatives. Consider the pros and cons of each possibility. Break complex tasks and activities down into smaller steps. Avoid situations that are over-stimulating (e.g., noise, crowds). Encourage the individual with a brain injury to ask others to slow down and repeat information. Get the individual’s attention when trying to teach, do, or discuss something. Break new information down into categories or “chunks.” List and review them in order. Talk to the individual with a brain injury about the activities and events of the day to help build memory. Present information in more than one way, including hearing, seeing, and doing. Each person has a different learning style. Have a place for everything and keep everything in its place. Don’t accuse the individual of lying.

Substitute Decision Making

GUARDIANSHIPS GUARDIANSHIPS (Minn. Stat. §§ through ) Court-ordered authority to act for an incapacitated individual, an individual lacking sufficient understanding or capacity to make or communicate responsible personal decisions, and who has demonstrated deficits in behavior which evidence an inability to meet personal needs for medical care, nutrition, clothing, shelter, or safety, even with appropriate technological assistance. The individual under guardianship is called the ward.

RIGHTS OF A WARD RIGHTS OF A WARD (Minn. Stat. § ) The ward retains all rights not restricted by court order and these rights must be enforced by the court. These rights include the right to: (1) treatment with dignity and respect; (2) due consideration of current and previously stated personal desires, medical treatment preferences, religious beliefs, and other preferences and opinions in decisions made by the guardian; (3) receive timely and appropriate health care and medical treatment that does not violate known conscientious, religious, or moral beliefs of the ward; (4) exercise control of aspects of life not delegated specifically by court order to the guardian; (5) guardianship services individually suited to the ward’s conditions and needs;

RIGHTS OF WARD, cont. (6) petition the court to prevent or initiate a change in abode; (7) care, comfort, social and recreational needs, training, education, habilitation, and rehabilitation care and services, within available resources; (8) be consulted concerning, and to decide to the extent possible, the reasonable care and disposition of the ward’s clothing, furniture, vehicles, and other personal effects, to object to the disposition of personal property and effects, and to petition the court for a review of the guardian’s proposed disposition; (9) personal privacy; (10) communication and visitation with persons of the ward’s choice, provided that if the guardian has found that certain communication or visitation may result in harm to the ward’s health, safety, or well-being, that communication or visitation may be restricted but only to the extent necessary to prevent the harm;

RIGHTS OF WARD, cont. ( 11) marry and procreate, unless court approval is required, and to consent or object to sterilization as provided in section , paragraph (c), clause (4), item (iv); (12) petition the court for termination or modification of the guardianship or for other appropriate relief; (13) be represented by an attorney in any proceeding or for the purpose of petitioning the court; and (14) vote, unless restricted by the court.

GUARDIAN’S DECISION- MAKING POWERS Establish a place of residence; Provide for the care, comfort, maintenance (food, clothing, shelter, health care, social and recreational, training, education, habilitation, rehabilitation); Take care of personal effects; Give or withhold consent for medical or other professional care, counsel, treatment, or service; Apply for and use governmental services and benefits; Approve or withhold approval of contracts.

TYPES OF SUBSTITUTE DECISION MAKING Substituted JudgmentBest Interests Substituted judgment means the guardian makes decisions for the ward based on how the ward would have decided if not incapacitated. This requires that the guardian knew the person, or is able to find out this information by interviewing people who did know the ward, before the ward became incapacitated. The guardian must also review any written statements or other declarations made by the ward before the ward or became incapacitated. Best interest has two parts: 1.The first part considers the ward’s wishes. 2.The second part considers the benefits and harms to the ward of a particular act or course of action based on reasonable alternatives, and selects a reasonable alternative that provides the most benefit and least harm. These decisions require the guardian to obtain enough knowledge of the ward in order to make decisions on the ward’s behalf that are in his or her best interest. Best interest requires that the guardian consider the least intrusive, most normalizing, and least restrictive course of action to provide for the needs of the ward.

PRINCIPLES OF ETHICAL DECISION MAKING Guardians are appointed to make decisions which will protect the ward’s civil and legal rights and personal freedoms. Guardians must take actions and make decisions that encourage and allow the maximum level of independent or self-reliant functioning on the part of the ward. Guardians must consider the ward’s preferences and desires. Guardians must weigh and balance all the potential benefits or risks to the ward. Guardians must strive to develop a trusting, accessible relationship with the highest level of communication possible with the ward, family, and other significant persons. Guardians must safeguard and aggressively pursue protection of the ward’s interests. Guardians shall treat all professionals and service providers with respect and courtesy to enhance the working relationship between the provider, ward, and the guardian for the optimal benefit of the ward.

TOPS TIPS FOR EFFECTIVE COLLABORATION 1.Communicate Clearly and Often 2.Give Feedback When Most Effective 3.Use Active Listening Techniques 4.Give Positive Reinforcement 5.Respect the Dignity of Risk

1.COMMUNICATE CLEARLY AND OFTEN “The single biggest problem in communication is the illusion that it has taken place.” - George Bernard Shaw

2. GIVE FEEDBACK WHEN MOST EFFECTIVE

3. USE ACTIVE LISTENING TECHNIQUES

4.GIVE POSITIVE REINFORCEMENT

5.RESPECT THE DIGNITY OF RISK “The world in which we live is not always safe, secure and predictable... Every day that we wake up and live in the hours of that day, there is a possibility of being thrown up against a situation where we may have to risk everything, even our lives. This is the way the real world is. We must work to develop every human resource within us in order to prepare for these days. To deny any person their fair share of risk experiences is to further cripple them for healthy living.” - Robert Perske

QUESTIONS?