Legal Analogies in Cicero's Political Thought.

Cicero's political thought is pervaded by analogies of private law that helped him to overcome philosophical difficulties. One serious difficulty was the demand of natural law that property must be owned by the one capable of managing it. This posed a problem to that most remarkable piece of property of all: the res publica. While incapable of managing it, the people was the only theoretically possible owner of the res publica. The legal concept "guardianship" offered a solution. In Cicero's writings the minor, guardian, and object under care demonstrably correspond to the Roman people, the magistrates, and the res publica.

On legal guardianship: An exploratory assessment of knowledge, attitudes and practices of resident physicians.

BACKGROUND: Clinicians encounter patients under legal guardianship. We aimed to assess the knowledge, attitudes and practices (KAP) on legal guardianship in residents. METHODS: A KAP pilot survey about legal guardianship was developed by an interdisciplinary medicine-law-public health team and was distributed via institutional email to internal medicine, psychiatry, and neurology residents in a single academic institution. RESULTS: Of the 172 invited residents, 105 (61%) responded and 102 surveys were included in the final analysis. Most respondents (58% women; internal medicine 73%, neurology 15%, psychiatry 12%) had attended 42 medical schools from 16 countries and had heard about guardianship (88%), but only 23% reported having received training on guardianship during medical school or residency. The vast majority (97%) understood the intended benefit of guardianship, but only 22.5% reported knowing that guardianship removed an individual's decision-making rights. Nearly half (47%) of respondents reported never having asked for documentation to prove that an individual was a patient's guardian, and only 15% expected to see a court order as proof of guardianship status. CONCLUSIONS: Although most residents intuitively understood the intended benefit of guardianship, they did not understand its full implications for clinical practice. Training interventions are warranted.

St. Zenobius, the Patron Saint of Injured Children and Non-accidental Trauma.

St. Zenobius (337-417), second only to John the Baptist as a Patron Saint of Florence, revived a 5-year-old boy who appeared to be dead after he was struck by an ox cart, one of his several acts of resurrection for which he was revered. His miracles inspired some of the greatest artists of the Florentine Republic, including Ghiberti and Botticelli. Celebrated from Late Antiquity as protector of the city, St. Zenobius might also be considered the guardian of injured children. But it wasn't the only instance where he had to revivify an injured child: a boy died while he was entrusted to the saint's care, a circumstance that today would qualify as non-accidental trauma (NAT) from neglect and prompt an investigation from the police and child protective services.

Diversified caregiver input to upgrade the Young Children's Participation and Environment Measure for equitable pediatric re/habilitation practice.

BACKGROUND: Practitioner and family experiences of pediatric re/habilitation can be inequitable. The Young Children's Participation and Environment Measure (YC-PEM) is an evidence-based and promising electronic patient-reported outcome measure that was designed with and for caregivers for research and practice. This study examined historically minoritized caregivers' responses to revised YC-PEM content modifications and their perspectives on core intelligent virtual agent functionality needed to improve its reach for equitable service design. METHODS: Caregivers were recruited during a routine early intervention (EI) service visit and met five inclusion criteria: (1) were 18 + years old; (2) identified as the parent or legal guardian of a child 0-3 years old enrolled in EI services for 3 + months; (3) read, wrote, and spoke English; (4) had Internet and telephone access; and (5) identified as a parent or legal guardian of a Black, non-Hispanic child or as publicly insured. Three rounds of semi-structured cognitive interviews (55-90 min each) used videoconferencing to gather caregiver feedback on their responses to select content modifications while completing YC-PEM, and their ideas for core intelligent virtual agent functionality. Interviews were transcribed verbatim, cross-checked for accuracy, and deductively and inductively content analyzed by multiple staff in three rounds. RESULTS: Eight Black, non-Hispanic caregivers from a single urban EI catchment and with diverse income levels (Mdn = $15,001-20,000) were enrolled, with children (M = 21.2 months, SD = 7.73) enrolled in EI. Caregivers proposed three ways to improve comprehension (clarify item wording, remove or simplify terms, add item examples). Environmental item edits prompted caregivers to share how they relate and respond to experiences with interpersonal and institutional discrimination impacting participation. Caregivers characterized three core functions of a virtual agent to strengthen YC-PEM navigation (read question aloud, visual and verbal prompts, more examples and/or definitions). CONCLUSIONS: Results indicate four ways that YC-PEM content will be modified to strengthen how providers screen for unmet participation needs and determinants to design pediatric re/habilitation services that are responsive to family priorities. Results also motivate the need for user-centered design of an intelligent virtual agent to strengthen user navigation, prior to undertaking a community-based pragmatic trial of its implementation for equitable practice.

Preventing Abuses in Guardianship Cases.

Guardianships allow court-appointed guardians to make decisions on behalf of persons who are incapable of caring for themselves. With their authority frequently extending over both the personal and the financial affairs of a ward, guardians sometimes abuse their extensive powers. Misuse of funds, excessive fees, and neglect of the ward's needs all have been seen in guardianship cases. As awareness of this problem has grown, innovative approaches have been developed to prevent and detect abuses, including mandatory certification, centralized audits, and visits to persons under guardianship to assess their status. Funding such efforts, however, remains a challenge.

[Guardianship law - what doctors and patients should know about the latest amendment]. / Das reformierte Betreuungsrecht und die Folgen für die Arztpraxis.

With the latest amendment of the guardianship law the German legislator means to strengthen the patients' right of self-determination. The most significant new regulations are the introduction of mutual legal representation of married couples in emergency and changes restricting the guardian's legal position. New challenges for doctors and lawyers arise especially from the legal representation of married couples. General practitioners who advise their patients with the preparation of provision documents should particularly explain the importance of recordations in the central providing register (ZVR).

From Guardianship to Supported Decision-Making: Still Searching for True North?

This article argues that asking whether guardianship has changed is the wrong question. It is the wrong question because guardianship does not exist in isolation from other institutions and legal instruments, such as enduring powers and nominee powers, or informal community arrangements of support or substituted decision-making. It is the wrong question because archetypical purity of guardianship as substitution and support as autonomy does not reflect real world experience of it as it is always a mixture of both, changing over time and decision type; and because change is very hard to pin down. In place of arid debates about whether guardianship should be modified or abolished, the better question to ask is where guardianship and its associated institutions fit within an ideally configured holistic package of formal and informal measures, and whether there are any indications of progress towards its realisation, or how that might be achieved.

Adolescent patient portals and concerns about confidentiality.

PURPOSE OF REVIEW: To better understand confidentiality issues that arise from adolescent access to patient portals. RECENT FINDINGS: Studies have evaluated the views of teens, parents, providers, and institutional leadership on adolescent patient portals and the risks they pose to adolescent privacy. Additional investigations have shown that teen portal accounts are often inappropriately accessed by parents. Guidelines are needed to better inform the creation of secure teen patient portals. Adolescent providers and other medical staff should be aware of the information available on portals, how to ensure portals are being accessed appropriately, and the potential for confidentiality breaches that come with portal use. Medical organizations that offer portal access need to provide resources to adolescents and their families to improve understanding around the importance of confidential care and how to maintain confidentiality while still engaging meaningfully with the healthcare system through patient portals. SUMMARY: Adolescents realize the benefits portals may offer regarding improved understanding of their health conditions, communication with their providers, and autonomy in their healthcare decisions. However, confidentiality of patient portals is a major concern and a potential barrier to adolescent portal utilization. Adolescent providers should be aware of the limitations of portal systems and advocate for improved confidentiality functionality to ensure teens can access the benefits of patient portals without any harm.

Guardianship Before and Following Hospitalization.

When ethics committees are consulted about patients who have or need court-appointed guardians, they lack empirical evidence about several common issues, including the relationship between guardianship and prolonged, potentially medically unnecessary hospitalizations for patients. To provide information about this issue, we conducted quantitative and qualitative analyses using a retrospective cohort from Veterans Healthcare Administration. To examine the relationship between guardianship appointment and hospital length of stay, we first compared 116 persons hospitalized prior to guardianship appointment to a comparison group (n = 348) 3:1 matched for age, diagnosis, date of admission, and comorbidity. We then compared 91 persons hospitalized in the year following guardianship appointment to a second matched comparison group (n = 273). Mean length of stay was 30.75 days (SD = 46.70) amongst those admitted prior to guardianship, which was higher than the comparison group (M = 7.74, SD = 9.71, F = 20.75, p < .001). Length of stay was lower following guardianship appointment (11.65, SD = 12.02, t = 15.16, p < .001); while higher than the comparison group (M = 7.60, SD = 8.46), differences were not associated with guardianship status. In a separate analysis involving 35 individuals who were hospitalized both prior to and following guardianship, length of stay was longer in the year prior (M = 23.00, SD = 37.55) versus after guardianship (M = 10.37, SD = 10.89, F = 4.35, p = .045). In qualitative analyses, four themes associated with lengths of stay exceeding 45 days prior to guardianship appointment were: administrative issues, family conflict, neuropsychiatric comorbidity, and medical complications. Our results suggest that persons who are admitted to hospitals, and subsequently require a guardian, experience extended lengths of stay for multiple complex reasons. Once a guardian has been appointed, however, differences in hospital lengths of stay between patients with and without guardians are reduced.

Waiting for guardianship in a public hospital geriatric inpatient unit: a mixed methods observational case series.

BACKGROUND: Patients in acute hospital settings waiting for guardianship and financial management (FM) hearings experience extended length of stay (LOS), with known consequences for frail elderly. This, together with universal agreement that substitute decision-making is a last resort measure, an imperative exists to examine guardianship and FM applications made from within hospital for geriatric inpatients. AIMS: This study aims to examine processes around Guardianship applications in a public hospital Geriatric inpatient setting including times to, reasons for and outcomes of referral; and to explore the content of the medical records in relation to criteria for application. METHOD: This was a mixed methods observational case series using descriptive data supplemented by qualitative case-note analysis of inpatients referred for guardianship (with/without FM) from 2018 to 2020 in a New South Wales Geriatric Medicine inpatient unit. Medical records were examined for evidence of operationalised criteria for guardianship, aligned with disability, capacity and need/risk common to most Australian jurisdictions. RESULTS: Of 45 patients with guardianship applications, 98% were granted guardians and 33 of 37 (89%) FM applications. Multiple risks underpinned applications, most commonly frequent falls (49%) and medication mismanagement (49%). Although only 29% were in receipt of services preadmission, 98% were discharged to residential care. Average hospital LOS was 70 days (interquartile range, 35), contributed to by delays between admission and decision to apply for guardianship/FM (median, 28 inpatient days) and uncertainties around or lack of documented capacity assessments. CONCLUSION: This study identifies potential points along pathways towards guardianship in hospital settings, which might be targeted to streamline if not divert some of these applications. Points of intervention include at initiation of applications, with consideration of alternatives to substitute decision-making by addressing patient needs and using supported decision-making, while improving clinician understanding of capacity assessment and guardianship.

Temporalidade no estabelecimento do vínculo parento-filial em adoções malsucedidas / Temporality in establishing the parent-child bond in unsuccessful adoptions / Temporalidad en el establecimiento del vínculo padre-hijo en adopciones fallidas

Este estudo é parte de uma ampla investigação sobre a vivência do processo de adoção malsucedida de crianças e adolescentes sob a perspectiva dos adotantes. Foi realizada uma pesquisa qualitativa, com base em entrevistas semiestruturadas com 11 sujeitos independentes, nove mulheres e dois homens, moradores de diferentes estados do Brasil, que vivenciaram adoções malsucedidas. Buscamos analisar as percepções dos adotantes relacionadas à temporalidade no estabelecimento do vínculo parento-filial nessas adoções. A temporalidade da gestação simbólica foi vivenciada pelos participantes de diferentes formas, podendo ser afetada pela lentidão no processo administrativo e/ou por fantasias e idealizações referentes à origem da criança/adolescente. Tanto a demora quanto a tentativa de agilização do processo de adoção são fatores que podem gerar ansiedade na experiência da gestação simbólica e que não serão amparados no tempo cronológico, afetando o estabelecimento do vínculo parento-filial. Ressaltamos a relevância do cuidado nos períodos iniciais de construção do vínculo parento-filial, considerando a temporalidade particular de cada caso e a história pregressa da criança/adolescente, aspecto que influencia o sucesso do processo de adoção.(AU)

This study is part of a broad investigation about the experience of the unsuccessful adoption process of children and adolescents from the perspective of the adopters. Qualitative research was carried out, based on semi-structured interviews with 11 independent subjects, nine women and two men, living in different states of Brazil, who experienced unsuccessful adoptions. We seek to analyze the perceptions of adopters related to the temporality in establishing the parent-child bond in these adoptions. The temporality of the symbolic gestation was experienced by the participants in different ways, which can be affected by the slowness of the administrative process and/or by fantasies and idealizations regarding the origin of the child/adolescent. Both the delay and the attempt to speed up the adoption process are factors that can generate anxiety in the experience of symbolic gestation and that will not be supported in chronological time, affecting the establishment of the parent-child bond. The relevance of care stands out in the initial periods of parent-child bond construction considering the particular temporality of each case and the child's/adolescent's past history, aspect that influences the success of the adoption process.(AU)

Este estudio es parte de una extensa investigación sobre la experiencia del proceso fallido de adopción de niños y adolescentes desde la perspectiva de los adoptantes. Se realizó una investigación cualitativa a partir de entrevistas semiestructuradas con 11 sujetos independientes, nueve mujeres y dos hombres, residentes en diferentes estados de Brasil, que experimentaron adopciones fallidas. En este trabajo se analizan las percepciones de los adoptantes relacionadas con la temporalidad en el establecimiento del vínculo padre-hijo en adopciones fallidas. La temporalidad del embarazo simbólico fue vivida por los participantes de diferentes formas, las cuales pueden verse afectadas por la lentitud del proceso administrativo y por fantasías e idealizaciones sobre el origen del niño/adolescente. Tanto la demora como el intento de agilizar el proceso de adopción pueden generar ansiedad por la vivencia del embarazo simbólico y que no serán sustentados en el tiempo cronológico, lo que afecta establecer este vínculo. Se enfatiza la relevancia del cuidado en los períodos iniciales de construcción del vínculo considerando la temporalidad particular de cada caso y la historia pasada del niño/adolescente, un aspecto que influye en el éxito del proceso de adopción.(AU)

Parental waivers to enable adolescent participation in certain forms of health research: lessons from a South African case study.

BACKGROUND: The South African legal framework requires mandatory parental/legal guardian consent for all research with children. Ethics guidelines provide some reprieve by allowing RECs to grant waivers of parental or guardianship consent in certain defined circumstances. In the first instance, consent may be provided by a proxy when parents or guardians are unavailable, for example with orphaned children. In the second instance, guidelines permit adolescent self-consent when the nature of the study justifies this approach, for example, research on sensitive issues like sexual behaviour or substance use. DISCUSSION: South African guidelines set several conditions that must be met for waivers to be granted. These norms overlap with those in international guidelines. However, the ethical norms, especially related to self-consent are sometimes vague. This article critically evaluates the consent norms in the national ethics guidelines and makes recommendations for reform to ethics guidelines in a way that recognises the value of child participation in research, their evolving decision-making capacity and their best interests. CONCLUSION: Recommendations are made to harmonise ethics guidelines and law in a way that promotes child participation in research, to ensure additional protections for adolescents when self-consent is allowed, and to withdraw procedural requirements for the community endorsement of self-consent strategies.

Estado nutricional población pediátrica y funcionalidad familiar en una unidad educativa ecuatoriana / Pediatric population nutritional status and family functionality in an Ecuadorian educa-tional unit

El estado de la funcionalidad de la familia influye en la calidad nutricional de sus miembros. El objetivo del presente estudio fue describir el estado nutricional de población pediátrica y la funcionalidad familiar en una unidad educativa pública en la provincia Cotopaxi, Ecuador, durante 2020. Se desarrolló una investigación descriptiva transversal, en la que participaron 179 familias de alumnos con edades entre 5 y 19 años, cuyos padres o tutores legales aportaron los datos de interés. La población pediátrica estuvo conformada por 91 niños/as de 5 a 9 años y 88 adolescentes de 10 a 19 años. El 54,7% correspondió al sexo femenino. En este contexto predominó el estado nutricional normal en los menores de edad y las familias funcionales (57%). La funcionalidad familiar se asoció significativamente con el grupo etario y el estado nutricional atendiendo a la talla/edad. Sin embargo, esa variable resultó independiente con respecto al estado nutricional según IMC/edad.

The state of family functionality influences the nutritional quality of its members. This study aimed to describe the nutritional status of the pediatric population and family functionality in a public educational unit in the Cotopaxi province, Ecuador, during 2020. A cross-sectional descriptive research was developed. The population was constituted by 179 families of students aged between 5 and 19 years old, whose parents or legal guardians provided the data of interest. The pediatric population consisted of 91 children from 5 to 9 years old and 88 adolescents from 10 to 19 years old. 54.7% corresponded to the female sex. In this context, normal nutritional status prevailed in minors and functional families (57%). Family functionality was significantly associated with age group and nutritional status according to height/age. However, this variable was independent with respect to nutritional status according to BMI/age

The Cost of Medically Unnecessary Days Due to Waiting for Guardianship in a State Acute Hospital System.

Hospitals must do more with less, making efficiency a priority. Discharge delays create challenges for acute care hospitals. Some delays are due to patients waiting for a guardian-a person appointed to assist an adult who lacks decision-making capacity. Previous studies examine the burden of excess days in a single academic medical center (AMC); however, these institutions do not represent the entire hospital system. This descriptive study expands upon previous analyses by calculating the financial implications of medically unnecessary days in a state's hospitals to payers. Two models are presented: one calculates the gross patient service revenues required to support excess days; the other calculates the expense to hospitals. Results suggest that substantial funds are required to support excess days. Funds may be better allocated to support the health and well-being of people needing medical care or to address the cause of delays due to waiting for guardianship.

Guardianship: A medicolegal review for clinicians.

Guardianship may pose an ethical dilemma for physicians, who must balance protecting vulnerable patients from potential safety concerns with respecting their autonomy. Older adults with dementia are particularly susceptible to loss of independence and the ability to participate in medical decision making. To have the capacity for medical decision making, individuals must understand relevant information, appreciate their circumstances, demonstrate reasoning, and express a consistent choice free from coercion. Although capacity assessments are usually task-specific, geriatricians and other specialists may be asked to comment on capacity more globally. These determinations may be used to support a Petition for the Appointment of a Guardian of a Legally Incapacitated Adult, the legal process of pursuing guardianship in probate court. Assigned guardians may be known to the incapacitated individual (e.g., a family member or friend) or may be professional guardians with no prior relationship to the ward. Guardians are encouraged to use substituted decision-making, taking into account the ward's previously expressed values and preferences. Although a number of viable alternatives to guardianship exist, numerous systemic barriers may prevent these from being fully explored. The ongoing need for guardianship should be periodically revisited and reassessed. Data about guardians and wards is shockingly sparse, as there are no centralized databases. Laws and regulations for guardianships vary significantly between states. Physicians can serve as important allies and advocates for patients with cognitive impairment at risk of incapacity, can help preserve their autonomy for as long as possible, and ensure appropriate protections are in place if the patient does lose their decision-making ability.

Grado de información percibida por los tutores legales en el Consentimiento Informado en el servicio de Neumología y Alergia Infantil / Grau d'informació percebuda pels tutors legals en el Consentiment Informat de proves de provocació a Al·lèrgia Pediàtrica / Degree of information perceived by legal guardians in the Informed Consent of challenge tests in Pediatric Allergy

Introduction: Knowledge about the degree of information perceived by the legal guardians from the Informed Consent (IC) in pediatric setting is scarce. Objectives: To evaluate the degree of information perceived by legal guardians in the IC for challenge tests in Pediatric Allergy. Methods and Materials: It is a descriptive, observational and cross-sectional study of information assessment through a questionnaire, in the period April-May 2021. The questionnaire was developed by the author and his team on the base of a publicly available one. A descriptive and analytical statistical study was carried out using the SPSS 15.0 software. Results: Ninety-nine tutors with a mean age of 41 years were recruited, with 52% university, 27% professional, 17% secondary and 4% primary education. More than 70% of the sample positively rated the degree of information provided in relation to the procedure, its objective, its risk-benefit, and the dedication and decision time. 50% of the tutors negatively rated the information provided regarding alternative treatment, the possibility of denying and revoking the IC. The internal consistency of the questionnaire was very good, with a Cronbach's alpha value of 0.88. No correlation was found between the degree of perception and several demographic or clinical variables. Conclusions: The degree of information perceived by the tutors is very good in general. The information in relation to the alternative procedures, the possibility of rejection and revocation of the IC can be improved.

Introducción: Existe escasa información sobre el grado de información percibida por los tutores legales en el Consentimiento informado (CI) en el ámbito pediátrico. Objetivos: Evaluar el grado de información percibida por los tutores legales en el CI de pruebas de provocación en Alergia Pediátrica. Métodos y Materiales: Estudio descriptivo, observacional y transversal de valoración de información mediante cuestionario, en el período de abril-mayo de 2021. El cuestionario fue desarrollado por el autor y su equipo, tomando como base un cuestionario disponible en la literatura. Se realizó estudio estadístico descriptivo y analítico mediante el software SPSS 15.0. Resultados: Se reclutaron 99 tutores con una edad media de 41 años, con formación universitaria 52%, profesional 27%, secundaria 17% y primaria 4%. Más del 70% de la muestra calificó positivamente el grado de información proporcionada en relación al procedimiento, su objetivo, su riesgo-beneficio y el tiempo de dedicación y de decisión. Un 50% de los tutores calificó negativamente la información proporcionada en cuanto al tratamiento alternativo, posibilidad de negar y revocar el CI. La consistencia interna del cuestionario fue muy buena, con un valor de la alfa de Cronbach de 0.88. No se encontró correlación entre el grado de percepción y diversas variables demográficas o clínicas. Conclusiones: El grado de información percibida por los tutores es en general muy bueno. Las informaciones en relación a los procedimientos alternativos, la posibilidad de rechazo y revocación del CI fueron los puntos mejorables.(AU)

Introducció: Hi ha escassa informació sobre el grau d'informació percebuda pels tutors legalsal Consentiment informat (CI) a l'àmbit pediàtric. Objectius: Avaluar el grau d'informació percebuda pels tutors legals al CI de proves de provocació a Al·lèrgia Pediàtrica. Mètodes i Materials: Estudi descriptiu, observacional i transversal de valoració d'informació mitjançant un qüestionari, en el període d'abril-maig de 2021. El qüestionari va ser desenvolupat per l'autor i el seu equip, prenent com a base un qüestionari disponible a la literatura. Es va realitzar estudi estadístic descriptiu i analíticmitjançant el programari SPSS 15.0. Resultats: Es van reclutar 99 tutors amb una edat mitjana de 41 anys, amb formació universitària 52%, professional 27%, secundària 17% i primària 4%. Més del 70% de la mostra va qualificar positivament el grau d'informació proporcionada en relació amb el procediment, el seu objectiu, el risc-benefici i el temps de dedicació i de decisió. Un 50% dels tutors va qualificar negativament la informació proporcionada pel que fa al tractament alternatiu, possibilitat de negar i revocar el CI. La consistència interna del qüestionari va ser molt bona, amb un valor de l'alfa de Cronbach de 0,88. No es va trobar correlació entre el grau de percepció i diverses variables demogràfiques o clíniques. Conclusions: En general, el grau d'informació percebuda pels tutors és molt bo. Les informacions en relació amb els procediments alternatius, la possibilitat de rebuig i revocació del CI van ser els punts millorables.(AU)

Comparing the reliability and predictive power of child, teacher, and guardian reports of noncognitive skills.

Children's noncognitive or socioemotional skills (e.g., persistence and self-control) are typically measured using surveys in which either children rate their own skills or adults rate the skills of children. For many purposes-including program evaluation and monitoring school systems-ratings are often collected from multiple perspectives about a single child (e.g., from both the child and an adult). Collecting data from multiple perspectives is costly, and there is limited evidence on the benefits of this approach. Using a longitudinal survey, this study compares children's noncognitive skills as reported by themselves, their guardians, and their teachers. Although reports from all three types of respondents are correlated with each other, teacher reports have the highest internal consistency and are the most predictive of children's later cognitive outcomes and behavior in school. The teacher reports add predictive power beyond baseline measures of Intelligence Quotient (IQ) for most outcomes in schools. Measures collected from children and guardians add minimal predictive power beyond the teacher reports.