Respecting autonomy in the guardianship appointment process for individuals with dementia in Finland: Legal and medical perspectives

Ascertaining the individual’s views

This main category based on the legal experts’ responses consists of five subcategories: (1) Hearing the individual, (2) Consulting relatives, (3) Appointment of a legal counsel or guardian ad litem, (4) Ex officio investigation, and (5) Flexibility in court proceedings. The main category ascertaining the individual’s views was common to both legal experts and physicians, although it consisted of different subcategories in each case.

All the legal experts emphasised the importance of hearing the individual, justifying this by noting that appointing a guardian is a significant intrusion on autonomy:

Appointing a guardian interferes in a person’s life. And restricting legal capacity represents a very severe interference. Thus, a lot of listening and requirements are involved. We didn’t understand this when the law was enacted, but now we do, as the Supreme Court has issued decisions highlighting this . . . One must hear, discuss and review much more than in other matters. (LE4)

To ascertain the individual’s opinion, it is not sufficient to merely provide an opportunity to submit a written statement like in many other matters handled by the court. Instead, the individual’s opinion must be determined more effectively:

I see it starting with the bailiff assessing the situation and asking the potential client – if they can be asked – their opinion and writing down their response, so we always get the message if the potential client says guardianship is not needed or they strongly oppose it or something else. I strive to ensure that their voice is heard, even if they cannot provide a written statement. I readily call them to a court hearing if they oppose. (LE6)

However, several legal experts pointed out that there are specific characteristics related to the vulnerable position of individuals with dementia which can sometimes make respect for their autonomy merely superficial:

When hearing an individual, there is often an assumption and expectation of more self-determination or capacity for self-determination than exists. This leads to unpleasant situations, especially if relatives are contentious. Each one, in turn, whispers into the potential client’s ear, disparages others, and tells their own truths. As a result, the potential client’s opinion frequently changes based on who last spoke with them. (LE19)

This quote illustrates that determining the true opinions of individuals with dementia is challenging and requires special expertise from legal professionals.

Although all the legal experts expressed that hearing the client is a central issue when assessing the need for and appointing guardians, one district judge admitted to sometimes bypassing it:

I believe that at least in [large city], where the number of cases is considerable, there are judges who, based solely on the medical report, become convinced that it is no longer worthwhile to hear the person on the matter and do not send the bailiff to meet the person, but just rule on the case. I believe this happens, and I do it myself. (LE9)

Such a procedure does not meet the requirements of a fair hearing and does not allow for the exercise of autonomy. The quote shows that although the importance of hearing the potential client in guardianship cases is recognised, the rights of vulnerable individuals are compromised due to the considerable number of cases judges must rule on.

The importance of consulting relatives was considered almost self-evident by the legal experts:

I certainly consider it important to hear the relatives. It is a natural part of the matter. (LE19)

Consulting relatives was deemed particularly important in order to ascertain the previously expressed or presumed views of the individual. Presumed views refer to the assumptions made about what the person would want, especially in terms of their care and treatment, based on their preferences, values and beliefs as expressed before dementia set in. ⁵⁴ Prior or presumed views are respected if the individual is no longer able to communicate their views clearly due to severe dementia:

When a person cannot express their will in this matter, such as who should take care of them and how, and whether they trust someone, it is necessary to try to determine the person’s will somehow. These situations are difficult, and the answers are not visible in any medical reports; they only become clear from the relatives’ accounts. (LE1)

Legal experts also emphasised the importance of hearing multiple relatives, even though the law does not require it:

The legal obligation to hear is not very strict. The potential client and their spouse are heard, and who else is heard is left open. It would be good to consider hearing as many close relatives as possible to obtain sufficient information. (LE4)

Legal experts also recognise the risks associated with hearing relatives. For example, they noted that the relative being heard is often an heir of the individual with dementia. Therefore, the relative might promote their own financial interests in the case. Despite this risk, almost all legal experts considered hearing relatives to be one of the key measures during guardianship evaluation.

Among the legal experts interviewed, the district judges in particular regularly emphasised that the appointment of a legal counsel or guardian ad litem is a crucial means to ensure that the perspective of an individual with diminished capacity is considered when assessing the need for a guardian:

In my opinion, it [the appointment of a guardian ad litem] may be the most effective way to ensure that individuals receive the necessary support and assistance to express their perspective. (LE5)

In addition, some district judges require assessment of the individual’s presumed views:

It is also about more than just presenting the potential client’s opinion. It concerns the individual’s life history, what they have thought, done and truly wanted, and how they now perceive the situation and would perceive it if they understood everything. (LE4)

Hearing all parties thoroughly and comprehensive investigation were also considered highly significant for the final decision, as evidenced by the following quote:

In a way, the individual’s true situation, reality, becomes apparent in these investigations, and quite often leads to the rejection of guardianship applications. (LE7)

It is noteworthy that the option to appoint a legal counsel was mostly nominal according to the district judges, though it should be the primary option according to the law. Generally, district judges appointed a guardian ad litem for individuals with dementia instead of a legal counsel:

I almost always appoint a guardian ad litem – specifically a guardian ad litem and not a legal counsel. Because based on that [medical report], I have determined that their understanding has already diminished to the extent that they may not be able to independently manage the legal proceedings. (LE5)

The preference for appointing guardians ad litem may be due to the need to protect the client for the reason mentioned in the above quote. Alternatively, it may reflect the judge’s desire to hear a guardian ad litem’s perspective on a case. Notably, some legal experts have observed that, ideally, a guardian ad litem should communicate not only their client’s opinion but also their own assessment regarding the client’s need for legal guardianship.

However, one district judge admitted to occasionally bypassing this stage of the process:

I confess that sometimes I determine the need for guardianship to be clear, in that the individual doesn’t understand what is in their best interest at all, and legal protection does not require the appointment of a guardian ad litem. In this case I directly appoint a guardian, thinking that they can appeal to the Court of Appeal. This is probably not entirely in line with the principle of autonomy, because they no longer know how to appeal. (LE6)

Previous research has identified mental incapacity as one of the barriers to older people’s access to justice. ⁵⁵ The quote above indicates that, despite the recognition of this barrier caused by mental incapacity, legal protection for individuals with dementia remains, at times, nominal.

Most of the legal experts highlighted that an important method to ensure autonomy is ex officio investigation. In other words, when a guardianship matter has been brought before the guardianship authority or a court, they must, by their own motion, determine whether the conditions for legal guardianship are met. This encompasses the proactive determination and thorough examination of factors influencing the necessity for appointing a guardian:

Well, maybe the consideration of the legal grounds for guardianship is then . . . a bit like that, where the case is very carefully scrutinised ex officio. (LE8)

The duty to investigate the case ex officio is based on Sections 78 and 91 of the Guardianship Services Act. The duty to conduct an ex officio investigation supports autonomy by ensuring that legal experts cannot automatically make conclusions on the case based solely on the fact that the individual has not provided a reply to the documents sent to them by the guardianship authority or a court. Failure to provide a written reply to the guardianship authority’s letter or to a court’s summons regarding the guardianship case cannot be interpreted as consent to the appointment of a guardian:

It is essential to ascertain whether the absence of a written reply from a potential client definitively means they do not oppose guardianship, or if it is the case that they oppose but have been unable to express their opposition. (LE9).

One interviewee mentioned becoming more actively involved to resolve these situations:

We often have to consider whether we need to personally visit the individual or, for example, contact healthcare staff – such as a medical social worker. (LE9)

Among the legal experts, several district court judges particularly highlighted flexibility in court proceedings. In practice, district judges have significant authority over how court proceedings are handled. Many district judges use this authority to ensure that the potential client is heard, as was mentioned as one of the goals of flexibility. For instance, being heard was regarded as such an important fundamental human right that a separate form for use in guardianship cases was developed in one district court. This form is delivered to potential client along with other documents related to the case. The following quote from a judge illustrates the practice of the district court:

We have made a very simple form, with very large letters so that even those with poor eyesight can read it. It simply states that the national guardianship authority has requested that a guardian be appointed to manage your financial affairs. Then there are checkboxes for ‘I agree’ and ‘I oppose’, ‘I want someone else to be my guardian’, ‘Anything else I want to say’, ‘Date and signature’ and then ‘Who helped fill out the form’. (LE7)

Neither the GSA nor the Code of Judicial Procedure require or mandate the use of such a form, which the judge who spoke about it also acknowledged. However, the judge considered that the use of the form is still justified:

This procedure is not fully compliant with the law, but it is in line with the purpose of the law. Perhaps we could think that an individual’s right to be heard in a guardianship matter is a human right, and the purpose of the law goes beyond its wording. (LE7)

Most judges also reported being flexible with the procedural order of disputes. Judges often described how the hearing on appointing a guardian should be organised according to the letter of the law but stated that they acted differently. Instead of strictly following the procedural order of disputes, the procedure was intended to be an occasion that best serves the goals of hearing and respecting the autonomy of the person with dementia. An example of this is the following quote:

I consider the hearing to be a positive and down-to-earth discussion forum, and I don’t aim to follow any procedural order for disputes, as I find it completely inappropriate for this type of case, and it doesn’t work. I aim for a conversational approach, with the constant goal of potentially reaching a consensus on the matter. (LE9)

The quote indicates that some legal experts consider hearing the individual to protect a central human right, to the extent that they are willing to deviate from rigid legal requirements to ensure that individuals with dementia are heard and their opinions considered. It is also noteworthy that not a single district registrar criticised the district judges for being flexible in court proceedings.

In addition, a few district judges openly stated that they inform the individual about the possibility of bringing the need for legal guardianship back to the court for reconsideration:

I tell the client that this may not necessarily be a final decision, that the decision can be revoked if the need no longer exists. (LE4)

Such guidance exceeds the court’s obligation to provide instructions for appeal. ⁵⁶ Providing guidance demonstrates a positive attitude towards autonomy on the part of the interviewees. It can be seen as supporting autonomy, although reassessment is primarily a theoretical possibility in cases of dementia, which is a progressive disease.

Minimising interference with autonomy

This main category consists of three subcategories: (1) Legal guardianship is a secondary measure, (2) Legal guardianship should take the least restrictive form possible and (3) The guardian chosen by the individual is prioritised.

All the legal experts emphasised that legal guardianship is a secondary measure in the management of an individual’s affairs. They stated that legal guardianship is considered only when no less restrictive alternative is found to be appropriate or available, which was noted to be due to the requirements of the Guardianship Services Act. This perspective is summarised in the following quotation:

The law sets the criteria that a person must be unable to manage their affairs due to their health condition and that there must be matters to be managed that cannot be managed by less restrictive means than guardianship. Even if their health is poor, if a close relative is already entitled to use their bank account, then matters can be handled by less restrictive means than guardianship. We do not proceed with the matter unless there is evidence of misuse or other issues. (LE14)

In addition, many interviewees stated that autonomy is respected in such a way that guardianship for personal matters, such as deciding on residence or giving consent to care, has a higher threshold than legal guardianship for financial matters. Instead of appointing a guardian, an individual with dementia is more likely to be allowed to make somewhat disadvantageous decisions regarding their personal affairs:

So, the threshold to appoint a guardian to make decisions on another person’s care, living arrangements or such matters, is really high; it usually involves cases where the person is clearly causing harm to themselves. (LE20)

One factor that raises the threshold for appointing a guardian for personal matters in Finland is that according to the Act on the Status and Rights of Patients (1992/785), consent for a patient’s treatment or for a certain measure to be taken can also be given by a close relative or other person closely connected with the patient if the patient cannot decide on the treatment to be given to them (Sections 6.2 and 6.3). In practice, this means that the matter can often be handled by a less restrictive measure than appointing a guardian. ⁵⁷

All the legal experts emphasised that autonomy should be respected by legal guardianship taking the least restrictive form possible. First, this is evident in the requirement that the guardianship should be as narrowly defined as possible, covering only those tasks for which guardianship is necessary:

We must intervene as little as possible. It is important that a guardian is appointed only for the tasks that absolutely require it. This is how autonomy is respected. (LE4)

Second, the effort to minimise restrictions is evident in the fact that rulings limiting an individual’s legal capacity, which significantly interfere with autonomy, are exceptional. The following quote exemplifies this:

I don’t recall any declarations of legal incompetence in recent years, except perhaps for cases where such a declaration has been revoked. Restrictions on legal capacity have also significantly decreased, and I can’t recall having to resort to such measures in cases related to dementia. (LE15)

This observation aligns with Finnish statistics on legal capacity restrictions. The number of legal capacity restrictions significantly decreased from the early 2010s to the early 2020s. While in the early 2010s the legal capacity of approximately 50 individuals was restricted per year, by the early 2020s this number had decreased to around 15 individuals per year. ⁵⁸ This highlights a substantial shift in the approach to the management of legal capacity over the decade. Although it is not typical to limit the legal capacity of individuals with dementia, the neuropsychiatric symptoms sometimes associated with dementia can lead to issues such as financial recklessness, ⁵⁹ necessitating consideration of such measures. ⁶⁰ Thus, despite their exceptional nature restrictions on legal capacity are not entirely excluded for individuals with dementia.

The rarity of restrictions on legal capacity is primarily attributed to legal requirements. However, some legal experts questioned whether it is necessary to limit legal capacity through a separate court decision at all. Legal guardianship was found to restrict a client’s ability to manage their own affairs even in its mildest form. This perspective is substantiated by legal research, which highlights the adverse impacts of legal guardianship on individual autonomy. ⁶¹ This criticism is also illustrated by the following quote:

When a guardianship is entered into the guardianship register, the supervision of the client may be stricter than necessary. This restricts their ability to act, even if they have legal capacity. Potential creditors may hesitate to grant credit, fearing it might later be invalidated, and all other avenues are closed as well. (LE16)

In addition, one legal expert noted that sometimes there is no need to restrict legal capacity because the client is unaware that they retain their legal capacity alongside the guardian:

It is fortunate that many clients believe they cannot do anything. In a way, it is positive that they think the guardian handles everything. I think that if the clients knew they were fully legally competent to perform legal acts, they would do so more often. (LE14)

This unawareness may serve as a protective mechanism, as highlighted by the quote, as clients do not always understand that they are allowed to engage in legal actions. This might lead to more compliance with guardianship decisions, as individuals might not challenge the authority’s actions. Nevertheless, clients’ lack of awareness of their own rights raises ethical questions about the transparency of authorities’ actions and the realisation of individuals’ autonomy and rights. If no one corrects the individual’s unawareness, the outcome for their daily life and perceived well-being is likely to be very similar, regardless of whether their legal capacity is formally restricted or stems from their own belief that it is restricted.

Respect for autonomy is also evident in the requirement that the guardian chosen by the individual is prioritised. This means that compelling reasons are needed to appoint a guardian whose identity is out of line with the individual’s views. The compelling reasons must be concrete and clear in order to override the client’s preference of guardian:

Of course, if the client has a clear desire to have someone as their guardian, I don’t really see why the court would not appoint that person. There must be strong counterarguments, such as evidence of abuse, conflict of interest, or some other concrete reason why the person desired by the client would not be suitable as a guardian. (LE16)

According to the Guardianship Services Act, the person appointed as a guardian must be suitable. In the assessment of suitability, the skills and experience of the nominee and the nature and extent of the duties must be taken into consideration, among other things (Section 5). Legal experts focused more on clear factors determining unsuitability rather than the suitability criteria given in the Act. The most common reason cited for the unsuitability of a guardian was debt enforcement:

Well, if there are 19 pages of debt enforcement records, then sorry, the potential client’s wishes can no longer be followed. (LE17)

Previous research has shown that older people count on their relations and safety nets for support to make decisions and plans. ⁶² Therefore, it is natural that persons with dementia also wish for a close person to be their guardian instead of a public guardian. If the individual’s wish to avoid the appointment of a guardian cannot be fulfilled, the least that can be done to respect their autonomy is to strive to respect their views regarding the identity of the guardian.

Ascertaining the individual’s views

This main category encompasses two subcategories: (1) Conducting a patient interview and (2) Consulting relatives.

All the physicians stated that conducting a patient interview is fundamental in assessing the need for legal guardianship, in order to ensure that their views are heard and respected. The interviewees also highlighted that efforts are made to respect verbally expressed views whenever possible:

I ask the patient their opinion on guardianship, as even the medical statement requires that the individual’s opinion be sought. I do not push for guardianship without clear grounds but rather follow what the individual wants. (P22)

This quote shows that the national guardianship authority’s template for medical reports indeed guides doctors to hear potential clients’ opinions. Several physicians also emphasised the way the interview should be conducted. Particular attention was paid to ensuring that the interview takes place without the presence of family members:

If a family member is present during the interview, they might take over and answer all the questions on behalf of the patient. Therefore, it is very important to meet the patient one-on-one. (P21)

Consideration of the individual’s current views and preferences, as highlighted by the interviewees, plays a pivotal and intrinsic role in the process of capacity determination. ⁶³ It is practically impossible to ascertain an individual’s perspective without hearing them in person. Furthermore, the literature emphasises the importance of interviewing the individual alone and for a sufficient time. ⁶⁴

In addition, a close and trusting relationship between the physician and the patient was also seen as a prerequisite for a successful interview, especially in situations where the patient is in a very vulnerable position:

The older, frailer, and weaker the elderly person is, the smaller their voice becomes compared to the voices of their family members. And family members do not always represent the best interests of the elderly. As a physician, you need to get close enough to the elderly person that they feel safe to express their own wishes. (P30)

This physician’s observation is consistent with the fact that older people are not often used to sharing ideas on their personal beliefs and commitments. ⁶⁵

All physicians said that consulting relatives is an important means to ascertain the individual’s views and avoid unnecessary appointment of a guardian. However, consulting relatives was sometimes described as an ideal, as the reality is that not all patients have relatives, or the physician may not always be able to talk with them. The importance of consulting relatives in order to ascertain the individual’s prior views was emphasised:

I ask my patients to name an individual that knows them well and with whom I could discuss the case with their permission. I then ask that person about what kind of thoughts my patient had, even twenty years ago, about the world, life, and their property in the future. Well, what were the important things for him or her? Because primarily, I would like to act as the patient would have always wanted their physician to act [regarding guardianship] before this illness occurred. (P20)

This quote indicates that the relatives of a person with dementia can play a significant role in determining what that individual’s prior views and preferences were before the onset of dementia. At the same time, it highlights the fact that a physician cannot contact a patient’s relatives without the patient’s consent. Balancing the prior and current views of persons with dementia is complex. The concept of precedent autonomy supports the idea that the views expressed by individuals before the onset of dementia should be respected. However, adhering to the prior views of individuals with dementia, especially if they later express that they have changed their mind, has faced criticism. ⁶⁶

Consulting relatives was also seen to ensure that protective measures are only taken if inappropriate behaviour is due to illness, not individual personality traits:

I always try to find someone who knows the patient well and can confirm whether this behaviour is new, which would indicate dementia, or if the person has always been like this, which could mean it is part of the patient’s personality and characteristic behaviour, that it is their lifestyle and a choice. In such cases, the threshold for intervention is significantly higher. (P21)

It is common for the personality and behaviour of individuals with dementia to change. ⁶⁷ However, unusual behaviour or behaviour that goes against one’s own interests does not always relate to dementia; it may simply reflect an individual’s unique personality. As noted in the above quote, the GSA stipulates that legal guardianship should be considered when the individual has a specific illness or otherwise impaired health condition.

Interestingly, many physicians pointed out that consulting relatives also serves the opposite purpose. Relatives play a crucial role in providing information if a potential client’s perspective on their own situation is unreliable, for example, due to anosognosia. In this way, consulting relatives can have a limiting effect on a potential client’s autonomy rather than supporting it.

Some participants also noted that consulting relatives may involve risks, for example if the relatives are unreliable. However, even the physicians who spoke about these risks emphasised that consulting relatives is important. To obtain a reliable picture of a potential client’s situation, information must be gathered as broadly as possible.

Experience has taught me not to take anyone’s word without questioning it. It is best to listen and try to investigate while remaining very impartial. But still to gather information as comprehensively as possible. (P30)

In addition, the physicians stressed the importance of careful execution of interviews with the potential client:

If there is any discrepancy between the accounts of the patient and their relatives, you must discuss this with the patient one more time. And absolutely ensure that no relatives are present. (P20)

Overall, family members can play a crucial role in enabling an individual’s autonomy, provided the physician considers family dynamics and patient safety when family members are present during a physician’s appointment. ⁶⁸

Supporting the realisation of the right to autonomy

The meaning of supporting the realisation of the right to autonomy was described in terms of three subthemes: (1) Empowering and guiding the individual, (2) Allowing the individual to manage their own affairs for as long as possible and (3) Seeking consensus with the individual.

Some physicians concluded that empowering and guiding the individual to exercise their autonomy is an essential part of their work. Physicians considered it important for patients to actively participate in managing their own affairs and to exercise their autonomy as much as possible:

We always investigate whether an enduring power of attorney exists, and if it does, we discuss with the patient whether to exercise it at this stage or not. The power of attorney simplifies matters, as guardianship is a bigger issue for many, including both the patient and the relatives. (P21)

The following quote demonstrates how dementia patients are guided to exercise their autonomy and actively work towards their overall well-being at a geriatric clinic:

We strive to empower patients. We place strong emphasis on non-pharmacological treatments and encourage patients to participate in their own care, particularly in terms of exercise and nutrition. When a patient comes for a first appointment, they are asked if they have made an advance health directive or enduring power of attorney. If they have not, our nurse provides information about these options. At the follow-up appointment, approximately six months later, we check whether the patient has taken any legal anticipatory steps. If not, we provide further briefing and encouragement to take these steps. (P13)

Such counselling is very supportive of autonomy, as older people sometimes lack knowledge about the various options available for successful later life legal planning, ⁶⁹ even though different measures and tools for legal planning are essential elements to secure the autonomy of people with dementia. ⁷⁰ Overall, the involvement of health care professionals in facilitating the realisation of the rights of people with dementia is essential. ⁷¹ By receiving information and encouragement related to the establishment of an enduring power of attorney, an individual can proactively prepare for incapacity and avoid legal guardianship, as their affairs are properly managed in another way. ⁷² This kind of autonomy-supporting and comprehensive counselling goes beyond health professionals’ obligation to provide information and guidance. ⁷³

Most physicians also considered that autonomy is primarily reflected in allowing the individual to manage their own affairs for as long as possible. The patient’s views should be respected if the patient does not endanger their own well-being or that of others:

If the patient strongly opposes guardianship but is safe, does not harm themselves or others, and has access to services such as meal delivery and home nursing, then guardianship should be avoided. (P6)

This perspective is well aligned with the principle of using the least restrictive means possible, as contemplated in the legislation concerning legal guardianship. ⁷⁴ However, some physicians deemed protection of the patient so paramount that the need for legal guardianship was primarily determined by the hypothetical worst-case scenario if a guardian was not appointed:

[To meet the need for guardianship] it is enough to have [impaired] understanding, because one day, for example, a telemarketer or some salesperson might come. Additionally, there are many close relatives who try to take advantage of people with dementia. So, it is the hypothetical idea of what would be the worst that could happen. (P29)

Such a view, which primarily emphasises threat assessment rather than evaluating whether the individual has personal or financial affairs that need to be managed, elevates the protection of the individual above autonomy. This perspective is not entirely in line with the requirements for legal guardianship as outlined in the Guardianship Services Act.

Furthermore, although respect for autonomy was generally considered important, the high threshold for appointing a guardian also received strict criticism from a few physicians:

From a doctor’s perspective, nowadays, the protection of autonomy has become so prioritised, even in cases of dementia, that a guardian is often appointed too late. (P1)

Some physicians pointed out that seeking consensus with the individual is part of respecting their autonomy. These physicians described how patients often understand the need for legal guardianship when they are openly informed about the nature of dementia and the purpose of a guardian:

Usually, when it is calmly explained to the patient that dementia is an insidious disease and causes problems that the patient does not notice themselves, things generally go well. Patients feel heard and understand that their financial situation is being safeguarded [by appointing a guardian] to prevent them from doing harm to themselves. (P25)

Striving for consensus was also considered important even in situations where the physician’s and the patient’s views on the need for legal guardianship do not align in the end:

If there are clear grounds for guardianship being genuinely necessary, then the statement is made to protect the patient. However, even in such situations, it must be communicated to the patient, and an attempt should be made to reach a consensus. (P20)

The interaction and mutual understanding between the physician and patient are central to patient autonomy and the physician-patient relationship. Investing in these aspects is worthwhile, as successful interaction not only supports patient autonomy but also positively influences their satisfaction, the development of trust and treatment outcomes. ⁷⁵

Providing accurate information on the legal process

This main category consists of two subcategories: (1) Proactively determining the factors affecting the need for legal guardianship and (2) Investing effort in writing a medical report.

Most physicians emphasised their responsibility to proactively determine the factors affecting the need for legal guardianship. The methods physicians use to assess the patient’s situation were described as multidisciplinary collaboration with other social and healthcare professionals:

The doctor needs a lot of information, often from a social worker, nurse specialised in neurocognitive diseases, or case coordinator in addition to the patient. Sometimes we also use occupational therapists to determine the patient’s actual functional capacity. So, assessment is often quite multi-professional. (P7)

Such proactive investigation supports the patient’s autonomy if it is determined that the patient’s affairs are being managed appropriately, but it can also result in the determination that the patient needs protection through legal guardianship.

Many physicians emphasised the obligation to invest effort in writing a medical report. As an autonomy-emphasising factor related to the content of the medical report, these interviewees highlighted the importance of recording the differing opinions regarding a potential client’s need for legal guardianship:

If necessary, I document that relative A says this, relative B says that, and the patient themself holds this opinion. I strive to ensure that these details are visible in the medical report when it is submitted to the deciding authority. (P24)

However, several physicians noted that the medical report should also include information that may have implications for autonomy if this information is crucial for the individual’s protection:

The report should reflect whether we have records of abuse by relatives. And if a relative is not suitable as a guardian, I have also documented that, in my opinion, the individual requires a public guardian. (P5)

Indeed, a public guardian may be appointed if there are no suitable family members or if family members are deemed unsuitable to act as guardians. ⁷⁶