Title: In re Guardianship of D.C.

State: massachusetts

Issuer: Massachusetts Supreme Court

Document:

NOTICE:  All slip opinions and orders are subject to formal 
revision and are superseded by the advance sheets and bound 
volumes of the Official Reports.  If you find a typographical 
error or other formal error, please notify the Reporter of 
Decisions, Supreme Judicial Court, John Adams Courthouse, 1 
Pemberton Square, Suite 2500, Boston, MA, 02108-1750; (617) 557-
1030; SJCReporter@sjc.state.ma.us 
 
SJC-12390 
 
GUARDIANSHIP OF D.C. 
 
 
 
Norfolk.     January 10, 2018. - May 11, 2018. 
 
Present:  Gants, C.J., Lowy, Budd, Cypher, & Kafker, JJ. 
 
 
Guardian.  Nursing Home.  Moot Question.  Probate Court, 
Guardian, Uniform practices.  Practice, Civil, Appointment 
of guardian, Moot case, Report. 
 
 
 
 
Petition for appointment of a guardian filed in the Norfolk 
Division of the Probate and Family Court Department on January 
26, 2016. 
 
 
The case was heard by George F. Phelan, J., and questions 
of law were reported by him to the Appeals Court. 
 
 
The Supreme Judicial Court on its own initiative 
transferred the case from the Appeals Court. 
 
 
 
Michael C. Boyne (Jessica L. Deratzian also present) for 
the hospital. 
 
Karen Owen Talley, Committee for Public Counsel Services, 
for D.C. 
 
Martin W. Healy, Thomas J. Carey, Jr., John J. Ford, Mark 
A. Leahy, Edward Notis-McConarty, Jerry Cohen, & Wynn A. 
Gerhard, for Martin W. Healy & others, amici curiae, submitted a 
brief. 
 
 
2 
 
 
 
GANTS, C.J.  The issue presented in this case is whether a 
Probate and Family Court judge has the legal authority to allow 
a hospital's request to transfer a patient to a skilled nursing 
facility where the judge did not find the patient to be an 
"incapacitated person," as defined in G. L. c. 190B, § 5-101 
(9), of the Massachusetts Uniform Probate Code (code), and 
therefore did not appoint a guardian for the patient.  We 
conclude that a judge does not have this legal authority.  Where 
a hospital patient refuses to consent to be transferred to a 
nursing facility, a judge may order the patient to be admitted 
to a nursing facility under the code only where the judge finds 
the patient to be an incapacitated person, and makes the other 
findings necessary to appoint a guardian under G. L. c. 190B, 
§ 5-306 (b), and then grants the guardian specific authority 
under G. L. c. 190B, § 5-309 (g), to admit the incapacitated 
person to a nursing facility after finding that such admission 
is in the incapacitated person's best interest.1 
 
Background.  On January 4, 2016, seventy-nine year old D.C. 
was admitted to a hospital in Cambridge after suffering a 
fracture of her left hip.  During the first month of her 
                                                          
 
 
1 We acknowledge the amicus brief and letter submitted by 
Martin W. Healy, Thomas J. Carey, Jr., John J. Ford, Mark A. 
Leahy, Edward Notis-McConarty, Jerry Cohen, Wynn A. Gerhard, the 
Massachusetts Chapter of the National Academy of Elder Law 
Attorneys, Massachusetts Guardianship Policy Institute, and 
Massachusetts Advocates for Nursing Home Reform. 
3 
 
 
hospitalization, D.C. also presented with acute renal failure, 
pancreatitis, and cardiac issues, and she underwent both a 
coronary bypass and a mechanical heart valve replacement.  D.C. 
refused to have hip surgery at the time and rejected all 
medications, including anticoagulants necessitated by her 
mechanical heart valve. 
 
The hospital's initial verified petition for appointment of 
a guardian for an incapacitated person and a motion for 
appointment of a temporary guardian were filed on January 26, 
2016.  The hospital alleged that D.C. was mentally incapacitated 
and unable to communicate; it also sought "specific [c]ourt 
authorization" to admit her to a nursing facility and, because a 
substitute judgment determination might be required, to "consent 
or withhold consent for the entry of a [Do Not Resuscitate, Do 
Not Intubate, and Comfort Measures Only] order."  The judge 
granted the petition for temporary guardianship on February 1, 
2016, and D.C.'s attorney was appointed as her temporary 
guardian.2  The temporary guardianship was extended on March 2 
                                                          
 
 
2 Temporary guardianships are in effect for ninety days (or 
longer "upon a finding of extraordinary circumstances") and may 
be extended thereafter for "good cause shown."  See G. L. 
c. 190B, § 5-308 (a) (where permanent petition for guardianship 
is pending, but court finds that waiting for permanent order 
would "likely result in immediate and substantial harm to the 
health, safety [or] welfare" of alleged incapacitated person, 
court may appoint temporary guardian pursuant to motion for 
temporary guardianship). 
4 
 
 
after a hearing, but lapsed on June 6, after the judge declined 
to extend the guardianship. 
 
The hospital filed another motion for appointment of a 
temporary guardianship in July, 2016, asserting that D.C. was an 
incapacitated person in need of guardianship based on her 
insistent refusal of medical care.  The medical certificate 
filed with the petition provided, among other things, that D.C. 
"has consistently demonstrated the inability to utilize the 
information given to her about her illness and [the hospital's] 
proposed treatment options," that her decisions are "putting her 
health and life in danger," and that she "lacks [the] capacity 
to make medical decisions at this time." 
 
On September 26, 2016, a different judge conducted a bench 
trial at the hospital on the petition for guardianship.  In a 
written decision dated November 15, 2016, the judge concluded 
that the hospital had failed to meet its burden of proving by a 
preponderance of the evidence that D.C. "is an incapacitated 
person within the meaning of G. L. c. 190B, § 5-101 (9) [and] 
that she is incapable of making decisions about medical 
treatment."  He determined that, "although she may be demanding, 
difficult, obstreperous and plainly refused to assist or 
participate with various medical care personnel at [the] 
hospital, [D.C.] has the capacity to discern her medical 
condition and needs with respect to anticoagulant medications 
5 
 
 
and hip replacement surgery, and has made [an] informed decision 
not to participate or engage with the [h]ospital personnel, 
understanding that her refusal of the medication may be 
seriously harmful or lead to her death, and further 
understanding that she requires a hip replacement which cannot 
proceed without her taking those medications."  He therefore 
dismissed the hospital's petition to appoint a guardian for D.C. 
 
However, the judge allowed the hospital's request that D.C. 
be transferred to a skilled nursing facility, finding that, 
notwithstanding D.C.'s refusal to take medications, her current 
medical condition "no longer requires an acute level of care and 
her medical needs can be met at a skilled . . . nursing 
facility." 
 
In November, 2016, the hospital moved for clarification of 
the court's judgment.  During a hearing on the hospital's 
motion, the judge reiterated his finding that the hospital had 
failed to prove that D.C. was an incapacitated person and 
declared that, having so found, he could not order any 
guardianship, even a limited guardianship, "solely for the 
purpose of admitting [D.C.] to a skilled nursing facility."  He 
also declined the hospital's request to issue an order regarding 
the hospital's authority to effectuate D.C.'s transfer to a 
skilled nursing facility, but he did not revoke his allowance of 
the hospital's request that she be transferred.  Instead, on his 
6 
 
 
own initiative, he reported three questions of law to the 
Appeals Court: 
1.  Must a guardian based on a finding of mental incapacity 
first be appointed over respondent to authorize petitioner 
to then admit respondent to a nursing facility? 
 
2.  Does the Massachusetts Probate and Family Court have 
the authority to appoint a "limited guardian," over a 
person not proven to be mentally incapacitated, solely for 
the purpose of admitting the respondent to a nursing 
facility? 
 
3.  Does the Massachusetts Probate and Family Court have 
the authority to order a not mentally incapacitated 
hospital patient to be transferred to a nursing facility? 
 
 
The hospital filed a notice of appeal from the judge's 
dismissal of the guardianship petition, and moved to consolidate 
that appeal with the reported matter.  The Appeals Court allowed 
the motion to consolidate, and we transferred the consolidated 
case to this court on our own motion. 
 
Before oral argument on the appeal, the hospital filed a 
new petition for guardianship, which the judge allowed.  On 
November 8, 2017, the judge found D.C. to be an incapacitated 
person, appointed a general guardian for her, and specifically 
granted the guardian the authority to admit D.C. to a nursing 
facility after finding that such admission was in D.C.'s best 
interest. 
 
Discussion.  1.  Mootness.  The judge's more recent 
allowance of the hospital's guardianship petition renders moot 
the appeal from the judge's dismissal of the earlier petition.  
7 
 
 
But an exception to the mootness doctrine exists "[w]here a case 
is 'capable of repetition, yet evading review,'" which may 
render dismissal on mootness grounds inappropriate.  Seney v. 
Morhy, 467 Mass. 58, 61 (2014), quoting Wolf v. Commissioner of 
Pub. Welfare, 367 Mass. 293, 298 (1975).  "In such 
circumstances, we do not hesitate to reach the merits of cases 
that no longer involve a live dispute so as to further the 
public interest."  Aime v. Commonwealth, 414 Mass. 667, 670 
(1993).  Here, we decline to reach the merits of the hospital's 
appeal from the judge's dismissal of the earlier guardianship 
petition inasmuch as it claims that the judge was clearly 
erroneous in finding that D.C. was not an incapacitated person.  
That finding, based on D.C.'s physical and mental condition at 
the time of the earlier hearing, is unique to her, and those 
specific factual circumstances are not "capable of repetition" 
in this or other cases. 
 
However, we shall address the matter reported by the judge, 
which concerns the lawfulness of allowing a hospital to transfer 
a patient involuntarily to a skilled nursing facility in the 
absence of a guardianship.  That particular issue is "capable of 
repetition and, given the short time periods in which 
guardianship matters are often decided and the fluidity of the 
proceedings even after an appointment of a guardian . . . , it 
is an issue that can easily evade appellate review in the 
8 
 
 
ordinary course."  Guardianship of V.V., 470 Mass. 590, 591-592 
(2015).  We also note that the guardianship petitions in this 
case were all filed after July 1, 2009, when the current 
provisions of the code governing guardianship of incapacitated 
persons went into effect.  See G. L. c. 190B, art. V, §§ 5–301 
to 5-313, inserted by St. 2008, c. 521, §§ 9, 44.  Since 2009, 
there has been little appellate jurisprudence interpreting these 
code provisions, and therefore little opportunity for us to 
provide further guidance that might advance "[u]niformity of 
treatment of litigants and the development of a consistent body 
of law" (citation omitted).  Zullo v. Goguen, 423 Mass. 679, 682 
(1996).  Because guardianship is of significant public 
importance, and because this case has been fully argued to us, 
we find it appropriate to address the questions posed by the 
judge.  See Superintendent of Worcester State Hosp. v. Hagberg, 
374 Mass. 271, 274 (1978).  See also Guardianship of Erma, 459 
Mass. 801, 804 (2011) (appeal of substituted judgment treatment 
order expired and moot, but court "comment[s] briefly on an 
issue . . . that has public importance, has been fully briefed 
and argued, and may recur under the [code]"). 
 
2.  Propriety of judge's reported questions.  The judge 
here declared that he was reporting three specific questions to 
the Appeals Court pursuant to Mass. R. A. P. 5, as amended, 378 
Mass. 930 (1979).  That particular rule, however, does not 
9 
 
 
confer authority on judges to report matters; it simply directs 
how reported matters are to proceed under the appellate rules 
once they reach an appellate court.  See Gray v. Commissioner of 
Revenue, 422 Mass. 666, 667 (1996).  The authority of trial 
judges to report matters derives from other court rules and 
statutes, and depends, in part, on the type of case and on which 
department of the Trial Court is involved.  See, e.g., Mass. R. 
Civ. P. 64, as amended, 423 Mass. 1410 (1996); Mass. R. Dom. 
Rel. P. 64; Dist./Mun. Cts. R. A.D.A. 5.  See also G. L. c. 231, 
§§ 108, 111. 
 
The authority of a Probate and Family Court judge to report 
matters in a guardianship case such as this derives from G. L. 
c. 215, § 13.  That statute permits a judge of the Probate and 
Family Court to report in two types of situations:  (1) where "a 
case or matter is heard for final determination," the judge "may 
reserve and report the evidence and all questions of law therein 
for consideration of the appeals court, and thereupon like 
proceedings shall be had as upon appeal"; and (2) if after 
making an interlocutory ruling, the judge "is of opinion that it 
so affects the merits of the controversy that the matter ought, 
before further proceedings [in the trial court], to be 
determined by the appeals court," the judge may report his or 
her interlocutory ruling for immediate appellate review.  See 
G. L. c. 215, § 13.  The first path places an undecided case 
10 
 
 
before the appellate court and puts the appellate court in a 
position to enter, or order the entry of, the final judgment in 
the first instance; the second path places before the appellate 
court the issue of the correctness of a significant 
interlocutory ruling made by a Probate and Family Court judge.  
See Dorfman v. Allen, 386 Mass. 136, 138 (1982); Paquette v. 
Koscotas, 12 Mass. App. Ct. 52, 54-55 (1981). 
 
The judge's report in this case does not appear to fit into 
either category of reports permitted by G. L. c. 215, § 13.  See 
Matter of Jones, 379 Mass. 826, 828 n. 2 (1980).  Nevertheless, 
as we occasionally do, we address the reported questions.  See, 
e.g., Gray, 422 Mass. at 668; Dorfman, supra at 138.  We do so 
because the questions raised by the report are important and of 
considerable public interest, and because we anticipate that our 
discussion of the issues will provide guidance to judges and 
attorneys in the future. 
 
3.  Legal authority under the code to admit a person 
involuntarily to a nursing facility.  The adoption of the code 
in July, 2009, resulted in a substantial revision to the State's 
statutory guardianship law.  See G. L. c. 190B, art. V, §§ 5–301 
to 5-313, inserted by St. 2008, c. 521, §§ 9, 44.  As compared 
with the previous statutory scheme, the "additional protections" 
offered under the code include a "more precise definition" of 
the terms "incapacity" and "disability," additional information 
11 
 
 
required of petitioners at the commencement of guardianship 
proceedings, and more elaborate reporting requirements for 
guardians.  See Article V, Protection of Persons Under 
Disability and Their Property, Massachusetts Comment, in The New 
MUPC Is Here . . . and Now at 227 (Mass. Cont. Legal Educ. 
2012). 
 
The legal standard to be applied when determining whether a 
guardian may be appointed over an individual requires us to read 
the definition of an incapacitated person under § 5-101 (9), 
together with the prerequisites for appointing a guardian under 
§ 5-306 (b).  Section 5-306 (b) provides that, after conducting 
a hearing, a court may appoint a guardian where the petitioner 
proves 
"(1) a qualified person seeks appointment; (2) venue is 
proper; (3) the required notices have been given; (4) any 
required medical certificate is dated and the examination 
has taken place within [thirty] days prior to the hearing; 
(5) any required clinical team report is dated and the 
examinations have taken place within 180 days prior to the 
filing of the petition; (6) the person for whom a guardian 
is sought is an incapacitated person; (7) the appointment 
is necessary or desirable as a means of providing 
continuing care and supervision of the incapacitated 
person; and (8) the person's needs cannot be met by less 
restrictive means, including use of appropriate 
technological assistance"  (emphasis added). 
 
See also G. L. c. 190B, § 1-201 (22) ("'Incapacitated person,' 
an individual for whom a guardian has been appointed under part 
3 of [G. L. c. 190B,] article V"). 
12 
 
 
 
The definition of an "incapacitated person" supplies the 
substantive grounds for appointing a guardian for an individual, 
for reasons apart from advanced age or youth.  See Article V, 
Protection of Persons Under Disability and Their Property, 
Prefatory Note, supra.  Under G. L. c. 190, § 5-101 (9), an 
"incapacitated person" is defined as 
"an individual who for reasons other than advanced age or 
minority, has a clinically diagnosed condition that results 
in an inability to receive and evaluate information or make 
or communicate decisions to such an extent that the 
individual lacks the ability to meet essential requirements 
for physical health, safety, or self-care, even with 
appropriate technological assistance." 
 
The standard of proof to be applied in a guardianship proceeding 
is a preponderance of the evidence, see G. L. c. 190B, § 1-109, 
and the burden of proof rests with the petitioner to prove that 
a person is incapacitated.  See Willett v. Willett, 333 Mass. 
323, 324 (1955). 
 
A guardianship may be general or limited in scope.  See 
G. L. c. 190B, § 5-303 (a) ("An incapacitated person or any 
person interested in the welfare of the person alleged to be 
incapacitated may petition for a determination of incapacity, in 
whole or in part, and the appointment of a guardian, limited or 
general").  When filing a petition for the appointment of a 
guardian for an incapacitated person, a petitioner must indicate 
on the form whether a general or limited guardianship is sought, 
and define the scope of the guardianship.  In the event that a 
13 
 
 
general guardianship is sought, the petitioner must offer an 
explanation as to why a limited guardianship is "inappropriate."  
"[T]he ability to create a limited guardianship is intended to 
maximize the liberty and autonomy of a person subject to 
guardianship."  Guardianship of B.V.G., 474 Mass. 315, 323 
(2016).3  Courts must exercise the authority conferred on them to 
"encourage the development of maximum self-reliance and 
independence of the incapacitated person and make appointive and 
other orders only to the extent necessitated by the 
incapacitated person's limitations or other conditions 
warranting the procedure."  G. L. c. 190B, § 5–306 (a). 
 
Even where a guardian is appointed, whether general or 
limited in scope, the guardian does not have the authority to 
admit the incapacitated person to a nursing facility4 against the 
                                                          
 
 
3 The Massachusetts Uniform Probate Code Prefatory Note to 
article V provides, in part, "The call for 'limited 
guardianship' was a call for more sensitive procedures and for 
appointments fashioned so that the authority of the protector 
would intrude only to the degree necessary on the liberties and 
prerogatives of the protected person.  In short, rather than 
permitting an all-or-none status, there should be an 
intermediate status available to the courts through which the 
protected person will have personal liberties and prerogatives 
restricted only to the extent necessary under the circumstances.  
The court should be admonished to look for a least-restrictive 
protection approach."    Article V, Protection of Persons Under 
Disability and Their Property, Prefatory Note, in The New MUPC 
Is Here . . . and Now at 227 (Mass. Cont. Legal Educ. 2012). 
 
 
4 With certain exceptions not relevant here, G. L. c. 190B, 
§ 5-101 (15) defines a "[n]ursing facility" as "an institution 
or a distinct part of an institution which is primarily engaged 
14 
 
 
will of the incapacitated person "except upon a specific finding 
by the court that such admission is in the incapacitated 
person's best interest."  G. L. c. 190B, § 5-309 (g).5  
Accordingly, the appointment of a guardian over an incapacitated 
person is necessary, but not by itself sufficient, to admit an 
incapacitated person to a nursing facility against his or her 
will.  Such an admission requires an additional order by the 
court based on a specific finding that the admission is in the 
incapacitated person's best interest. 
                                                                                                                                                                                           
in providing to residents:  (i) skilled nursing care and related 
services for residents who require medical or nursing care; (ii) 
rehabilitation services for the rehabilitation of injured, 
disabled or sick persons; or (iii) on a regular basis, health-
related care and services to individuals who because of their 
mental or physical condition require care and services, above 
the level of room and board, which can be made available to that 
individual only through institutional facilities that are not 
primarily a mental health facility or developmentally disabled 
facility." 
 
5 We note that, if five conditions are met, G. L. c. 190B, 
§ 5-309 (g) carves out an exception to the requirement that a 
guardian may admit an incapacitated person to a nursing facility 
only where a court specifically finds that admission is in the 
incapacitated person's best interest.  The five conditions are 
"(1) the admission shall not exceed [sixty] days; (2) any person 
authorized to sign a medical certificate recommends such 
admission; (3) neither any interested person nor the 
incapacitated person objects; (4) on or before such admission, a 
written notice of intent to admit the incapacitated person to a 
nursing facility for short term-services has been filed by the 
guardian in the appointing court and a copy thereof has been 
served in-hand on the incapacitated person and provided to the 
nursing facility; and (5) the incapacitated person is 
represented by counsel or counsel is appointed forthwith." 
15 
 
 
 
A Probate and Family Court judge does not have the 
authority under the code to allow a hospital's request to admit 
a patient to a skilled nursing facility against the will of the 
patient where, as here, the judge has not found the patient to 
be an incapacitated person and, therefore, has not appointed a 
guardian for that patient.  Indeed, even if the judge here had 
found D.C. to be an incapacitated person and appointed a 
guardian for her, the guardian would still lack the legal 
authority to admit D.C. to a nursing facility against her will 
unless the judge granted the guardian that specific authority by 
making a "specific finding" that it was in D.C.'s best interest 
to be admitted to a nursing facility. 
Nor does a Probate and Family Court judge have the 
authority under the code to appoint a limited guardian over a 
person for the narrow purpose of admitting that person to a 
nursing facility where the judge has not found the person to be 
an incapacitated person.  To be sure, where a person is found to 
be incapacitated, as defined in G. L. c. 190, § 5-101 (9), and 
"the principal reason for the guardianship is the [incapacitated 
person's] inability to comprehend a personal medical problem, 
the guardian's authority could be limited to making a judgment, 
after evaluation of all circumstances, concerning the 
advisability and form of treatment and to authorize actions 
necessary to carry out the decision."  Guardianship of B.V.G., 
16 
 
 
474 Mass. at 322, quoting Uniform Probate Code prior § 5-306 
comment, 8 U.L.A. (Part III) 186 (Master ed. 2013).  But that 
limited authority cannot be granted to a limited guardian 
without a finding that the person is an incapacitated person 
and, where the decision is to admit the person against his or 
her will to a nursing facility, without a specific finding by 
the court that such admission is in the person's best interest.  
Therefore, because the judge here made neither finding, the 
judge erred in allowing the hospital's request to transfer and 
admit D.C. to a skilled nursing facility.6 
Thus, we address the questions posed by the judge as 
follows: 
1.  A judge of the Probate and Family Court may not order a 
person to be admitted to a nursing facility against his or 
her will unless the judge appoints a guardian after finding 
that the person is an incapacitated person as defined in 
G. L. c. 190, § 5-101 (9), and then makes a specific 
finding that admission to a nursing facility is in the 
incapacitated person's best interest. 
 
2.  A judge of the Probate and Family Court does not have 
the authority to appoint a limited guardian over someone 
who is not an incapacitated person for the sole purpose of 
admitting that person to a nursing facility. 
 
3.  A judge of the Probate and Family Court does not have 
the authority to order someone who is not an incapacitated 
person to be transferred to a nursing facility. 
 
                                                          
 
 
6 We do not address the legal options available to an acute 
care hospital where a patient who is not incapacitated fails to 
leave upon discharge. 
17 
 
 
 
Conclusion.  For the reasons given, the hospital's appeal 
from the judge's order dated November 15, 2016, dismissing its 
petition to appoint a guardian for D.C., is dismissed as moot, 
and the subsequent report of the matter dated November 28, 2016, 
is discharged.  See Dorfman, 386 Mass. at 138 (discharging 
report that did not comply with G. L. c. 215, § 13). 
 
 
 
 
 
 
 
So ordered.