In June 2016, the Office of Public Guardian (OPG) became Temporary Guardian/Conservator for “Kyle.” Four months previously, Kyle had been hospitalized as a result of intervention by his VA primary care provider due to his frequent falls, dizziness, and weakness. His medical records indicate that Kyle was a “75 year old Caucasian male” who told doctors, “his knees were going out from under him at home” and “he knows he needs help.” His diagnosis included mental health issues that manifested with hallucinations and delusions; progressive supra-nuclear palsy (similar to Parkinsons), weakness, falls, and hypertension. The doctor also noted that he was very cooperative, pleasant, and looked much younger than he was.
Upon discharge from the hospital, Kyle went to a nursing home. The nursing home’s social worker noted he was in a wheelchair, but had frequent falls. The falls were a result of Kyle’s delusions that the floors under his wheelchair opened up into large holes. He fell out of his wheelchair when he tried to avoid the holes. Additionally, Kyle repeatedly experienced delusions of men in military uniforms hunting him down to kill him, “company men” or “CIA.” Kyle said they were trying to kill him for something he did 35 years ago. During the guardianship hearing, the social worker testified regarding his finances that Kyle had been turned down for Medicaid; his mail forwarded to the nursing home indicated his bills were not getting paid, including his house payment; his Medicare payments for rehab at the nursing home had run out and his nursing home bill was over $8,000. The social worker also testified Kyle was a Veteran, having spent 20 years in the U.S. Army. He did not have any family or friends to assist in his care, except a daughter in California. His daughter had agreed to act as POA for health care during his prior hospitalization, but did not want to be involved to any greater extent. She told the nursing home she did not have a relationship with her father, “he chose to end the relationship 35 years ago.” The social worker stated that Kyle had spent time in prison, in a different state, from 1984 to 2009 for sexual assault of a minor. After prison, he came to Nebraska to get a new start at life. She concluded that the staff at the nursing home was concerned Kyle was a vulnerable adult without anyone to assist with his finances or medical care and, due to his medical issues, he was unable to appropriately care for himself or fulfill his responsibilities.
After the OPG Temporary appointment, the Associate Public Guardian (APG) assigned to the case met with Kyle. The APG indicated Kyle was open and conversational, cognizant of time and his situation, able to share information regarding his personal life, but to Kyle the delusions were very real. Despite medication and reassurances no one was after him and the floors did not have holes, Kyle’s hallucinations and paranoia evoked true terror and flight response in him. In addition to meeting with Kyle, the APG set about discovering Kyle’s assets and debts, and addressing his financial problems. The APG discovered Kyle had pre-paid funeral arrangements and, through communications with Kyle’s daughter, obtained a hand written will Kyle had drafted in 2009.
OPG staff worked to secure Kyle’s house and his belongings. The house was a two bedroom, one and a half story home built in 1905. Kyle had worked hard on the house, replacing the roof, putting in new windows and siding. He and his neighbors had developed relationships that resulted in them voluntarily taking on the responsibility to mow his lawn, and keep an eye on his home while he was gone. When the APG went to Kyle’s home, the neighbors came over to talk about Kyle, and inquire how Kyle was doing. Inside the home, despite Kyle’s medical, mental and physical challenges, one could see that he worked to keep the house clean. His dishes were done, his bed was made, and his laundry was folded. His medications and mail sat where he had left them. It was clear that Kyle had planned on returning to his home and his life; instead APGs, as strangers (feeling almost as if they were invaders of his privacy) were there trying to decide how best to care for his things.
Shortly after the OPG took responsibility for Kyle, he was again hospitalized. For a second time, his VA health provider intervened for his care, concerned Kyle was losing weight, was dehydrated, and seemed more disoriented than normal. At the hospital, the diagnosis was grim. Kyle’s palsy was progressing, he had difficulty eating, and the doctors were concerned he would aspirate his food. A Palliative Care consult was requested. The APG and the Palliative Care provider talked with Kyle. The APG was there when Kyle was told the prognosis was for a rapid decline leading to his imminent death. Kyle had difficulty communicating, so the APG and the medical provider went through the end of life issues with him one step at a time. Did he want a feeding tube? No. Did he want a ventilator? No. Did he want CPR? Yes, but he would think about it and consider a different answer. Did he understand the plan was to discharge him to the nursing home under hospice care? Yes. The discussion ended, to be revisited with Kyle twenty minutes later to see if he remembered, understood, and reconfirmed his answers. He did. Kyle was discharged as planned. The APG communicated with the nursing home to ensure Kyle’s end of life wishes were respected and his medical and personal needs were addressed. It was determined that, if Kyle became unresponsive, the nursing home would provide CPR and call for emergency response. As expected, Kyle declined rapidly in the days to come. Kyle’s request for CPR continued and when he became unresponsive, CPR was performed. However, Kyle did not regain consciousness and was pronounced dead at the hospital. His funeral was performed as he wanted and, as per his will, his daughter was named as personal representative of his estate. He was a ward/protected person of the Office of Public Guardian for 32 days.